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7665777-1
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
This 60-year-old male was hospitalized due to moderate ARDS from COVID-19 with symptoms of fever, dry cough, and dyspnea. We encountered several difficulties during physical therapy on the acute ward. First, any change of position or deep breathing triggered coughing attacks that induced oxygen desaturation and dyspnea. To avoid rapid deterioration and respiratory failure, we instructed and performed position changes very slowly and step-by-step. In this way, a position change to the 135° prone position () took around 30 minutes. This approach was well tolerated and increased oxygen saturation, for example, on day 5 with 6 L/min of oxygen from 93% to 97%. Second, we had to adapt the breathing exercises to avoid prolonged coughing and oxygen desaturation. Accordingly, we instructed the patient to stop every deep breath before the need to cough and to hold inspiration for better air distribution. In this manner, the patient performed the breathing exercises well and managed to increase his oxygen saturation. Third, the patient had difficulty maintaining sufficient oxygen saturation during physical activity. However, with close monitoring and frequent breaks, he managed to perform strength and walking exercises at a low level without any significant deoxygenation. Exercise progression was low on days 1 to 5, but then increased daily until hospital discharge to a rehabilitation clinic on day 10.
[[60.0, 'year']]
M
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1
7665777-2
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
A 39-year-old man was hospitalized due to an increasingly reduced general health condition, after persistent fever and dry cough for 2 weeks. The patient initially needed 4 L/min of oxygen, had a rapid and shallow breathing pattern at rest and became severely breathless during minor physical activities. In the beginning, physical therapy focused on patient education about dyspnea-relieving positions, the importance of regular mobilization, and deep-breathing exercises. However, it quickly became evident that his anxiety from fear of dying and worries about his future aggravated his dyspnea and vice versa. The patient was so dyspneic, anxious, and weak that he was barely able to walk to the toilet. To counter this vicious circle, the physical therapist actively listened to the patient, explained why he was experiencing breathlessness, and tested suitable positions to relieve his dyspnea. He seemed to benefit from the education and the relaxing breathing exercises, as seen on day 2, when his respiratory rate could be reduced from 30 breaths/min to 22 breaths/min and his oxygen saturation increased from 92% to 96% on 4 L/min oxygen after guiding him through some deep-breathing exercises. Over the next days, his dyspnea and anxiety started to alleviate and he regained his self-confidence. Therapy was progressively shifted to walking and strength training and the patient rapidly advanced to walk 350 m without a walking aid or supplemental oxygen before his discharge home.
[[39.0, 'year']]
M
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2
7665777-3
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
One week after a positive COVID-19 result this 57-year-old male was admitted to the ICU because of oxygen desaturation (70%) with worsening tachypnea and dyspnea. Physical therapy started immediately after ICU admission. We found a highly dyspneic patient with a high breathing frequency and significant symptom exacerbation from the slightest effort. With hands-on physical therapy guidance, the patient managed to achieve a 135° prone position and to perform deep-breathing exercises resulting in an increase in oxygen saturation from 88% to 96%. Intensive physical therapy and positioning was continued along with 6 to 12 L/min of oxygen therapy over the next days and intubation was avoided. The major challenges in achieving a prone position were the patient’s profoundly reduced respiratory capacity and the high risk of exacerbating his symptoms. However, standard ICU monitoring enabled safe implementation at an individually adapted pace to allow sufficient time for convalescence. After 3 days with this regime, he could be transferred to the normal ward, where physical therapists carried on his rehabilitation with walking and strength training. The patient’s severe instability remained a challenge. Nevertheless, 9 days after ICU admission, the patient was able to leave the hospital as a pedestrian.
[[57.0, 'year']]
M
{'32320506': 1, '32293716': 1, '23219649': 1, '30339549': 1, '17470624': 1, '32280973': 1, '34789437': 1, '30427933': 1, '32191813': 1, '31064802': 1, '12493078': 1, '23688302': 1, '24552321': 1, '34602603': 1, '29208005': 1, '32312646': 1, '20046114': 1, '32250385': 1, '23886842': 1, '32345343': 1, '17885261': 1, '29023260': 1, '27940276': 1, '31768568': 1, '34953756': 1, '30113379': 1, '28847238': 1, '33492400': 2}
{'7665777-1': 2, '7665777-2': 2, '7665777-4': 2, '7665777-5': 2, '7665777-6': 2, '7665777-7': 2, '7665777-8': 2, '7665777-9': 2, '7665777-10': 2, '7665777-11': 2}
3
7665777-4
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
This 69-year-old male was admitted to the ICU after a dry cough for 2 weeks, oxygenation was poor and computer tomographic imaging showed typical COVID-19 pneumonia. Initially the patient received lung-protective ventilation and targeted sedation, but was otherwise stable. Treatment interventions included passive range of motion and positioning including passive mobilization into a side-edge position (). Over the next days, the patient deteriorated with hemodynamic instability and severe ARDS leading to intermittent prone positioning and continuous renal replacement therapy. The role of physical therapists during proning was to ensure correct joint positioning and pressure prophylaxis to prevent secondary complications such as nerve lesions, contractures, or pressure ulcers. Nevertheless, the long duration and repeated positioning resulted in a small pressure ulcer on the patient’s forehead. After tracheostomy, passive range-of-motion exercises, and passive side-edge mobilization were slowly resumed, whereby asynchronous ventilation and hemodynamic instability remained 2 major problems leading to further sedation and relaxation, thus inhibiting any active participation. After 24 days in the ICU, the patient scored 1/50 points on the Chelsea Critical Care Physical Assessment Tool (CPAx) and showed severe signs of muscle loss. The patient died soon after withdrawal of life support.
[[69.0, 'year']]
M
{'32320506': 1, '32293716': 1, '23219649': 1, '30339549': 1, '17470624': 1, '32280973': 1, '34789437': 1, '30427933': 1, '32191813': 1, '31064802': 1, '12493078': 1, '23688302': 1, '24552321': 1, '34602603': 1, '29208005': 1, '32312646': 1, '20046114': 1, '32250385': 1, '23886842': 1, '32345343': 1, '17885261': 1, '29023260': 1, '27940276': 1, '31768568': 1, '34953756': 1, '30113379': 1, '28847238': 1, '33492400': 2}
{'7665777-1': 2, '7665777-2': 2, '7665777-3': 2, '7665777-5': 2, '7665777-6': 2, '7665777-7': 2, '7665777-8': 2, '7665777-9': 2, '7665777-10': 2, '7665777-11': 2}
4
7665777-5
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
This 57-year-old male was admitted to the ICU with dyspnea, heavy dry cough, and fever 6 days after testing positive for COVID-19. Initially, he was able to exercise and sit in a chair with a physical therapist, but progressive respiratory failure necessitated intubation and proning. The patient had large amounts of bronchial mucus and required regular suctioning along with respiratory therapy. Secretions were assessed with pulmonary auscultation (presence of crackles) and by analyzing expiratory flow on the ventilator (sawtooth pattern). When suctioning failed to improve these clinical signs, 1 to 2 physical therapists used manual airway clearance techniques. The goal of these techniques was to sufficiently increase expiratory flow for effective airway clearance while avoiding alveolar collapse. To achieve this, manual compressions on the chest and abdomen were performed with just enough intensity to modify expiratory flow. After extubation, the patient was still unable to effectively clear his mucus due to weak cough. He continued to need intensive manual airway clearance techniques, nasal rinsing to induce cough and to help expectoration as well as upper and lower airway suctioning. To this end, the patient was treated up to 6 times per day/night. Additional physical therapist interventions included passive range of motion, assisted exercising, and mobilization. At the time of writing, the patient was still in the ICU without ventilatory support.
[[57.0, 'year']]
M
{'32320506': 1, '32293716': 1, '23219649': 1, '30339549': 1, '17470624': 1, '32280973': 1, '34789437': 1, '30427933': 1, '32191813': 1, '31064802': 1, '12493078': 1, '23688302': 1, '24552321': 1, '34602603': 1, '29208005': 1, '32312646': 1, '20046114': 1, '32250385': 1, '23886842': 1, '32345343': 1, '17885261': 1, '29023260': 1, '27940276': 1, '31768568': 1, '34953756': 1, '30113379': 1, '28847238': 1, '33492400': 2}
{'7665777-1': 2, '7665777-2': 2, '7665777-3': 2, '7665777-4': 2, '7665777-6': 2, '7665777-7': 2, '7665777-8': 2, '7665777-9': 2, '7665777-10': 2, '7665777-11': 2}
5
7665777-6
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
This 52-year-old male tested COVID-19 positive 4 days after the beginning of a dry cough, fever, and head and limb pain. One day later, he was hospitalized with exertional dyspnea. He was diagnosed with pneumonia that developed into moderate ARDS needing mechanical ventilation and intermittent dialysis. After extubation, oxygenation was stable with 2 to 3 L/min of oxygen. However, the patient was disoriented and could not communicate verbally. His global weakness (CPAx 11/50) was accompanied by oral and pharyngeal weakness and paresthesia. Spontaneous swallowing frequency and tongue control were severely reduced, and the patient showed insufficient protection from aspiration. This was confirmed by a specialized physical therapist with the Gugging Swallowing Screen, which confirmed severe dysphagia with 2/20 points. He was treated nil by mouth and received dysphagia therapy such as intensive oral stimulation, facilitation of swallowing, and training of protection mechanisms. After initial agitation and disorientation, the patient started to communicate in single-word phrases, but dysphagia continued to be severe with massive oral and pharyngeal dry saliva residuals that compromised his paresthesia and required regular mouth care. Over the next days, the patient managed to swallow pureéd food and mildly thick fluids under supervision, although cough strength was still weak (Gugging Swallowing Screen 13/20, CPAx 30/50). Nevertheless, he continued to progress and became capable of independent food ingestion (Gugging Swallowing Screen 20/20, CPAx 39/50) before his discharge to a rehabilitation clinic 25 days after admission.
[[52.0, 'year']]
M
{'32320506': 1, '32293716': 1, '23219649': 1, '30339549': 1, '17470624': 1, '32280973': 1, '34789437': 1, '30427933': 1, '32191813': 1, '31064802': 1, '12493078': 1, '23688302': 1, '24552321': 1, '34602603': 1, '29208005': 1, '32312646': 1, '20046114': 1, '32250385': 1, '23886842': 1, '32345343': 1, '17885261': 1, '29023260': 1, '27940276': 1, '31768568': 1, '34953756': 1, '30113379': 1, '28847238': 1, '33492400': 2}
{'7665777-1': 2, '7665777-2': 2, '7665777-3': 2, '7665777-4': 2, '7665777-5': 2, '7665777-7': 2, '7665777-8': 2, '7665777-9': 2, '7665777-10': 2, '7665777-11': 2}
6
7665777-7
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
Paramedics found this 59-year-old female with dyspnea and an oxygenation of 65% on room air and performed immediate tracheal intubation. Moderate ARDS with reduced lung compliance was diagnosed and treated with deep sedation, neuromuscular blocking agents, and prone positioning.\nOn day 14, a trial of sitting on the edge-of-bed (SOEB) was performed, while she was still intubated and under pressure support ventilation. SOEB required 3 physical therapists to maintain the position, but resulted in a significant increase in her level of consciousness and collaborative state. The next day, she was able to hold her head and sit for about 15 minutes with 2 therapists. Her muscle strength indicated ICU-acquired weakness, with a Medical Research Council sum-score (MRC-SS) of 40/60; still she continued with small but consistent improvements and started to participate actively in physical therapy sessions. She was encouraged to mobilize herself with exercises against gravity and was actively transferred to a chair each day with the help of 2 physical therapists. She was successfully extubated, but presented postextubation dysphagia. The physical therapy team closely monitored her for secretion management and cough stimulation and continued her physical rehabilitation. On day 19, she started to walk with a walking aid, although at this point oxygen desaturation during exercise training became evident (89% with 3 L/min of oxygen). After 25 days, she was transferred to the institution’s rehabilitation facilities, where a battery of tests indicated persistent physical function impairment (MRC-SS 52/60, physical function ICU test score17 9/12, Timed Up & Go 23 seconds, short physical performance battery 4/12).
[[59.0, 'year']]
F
{'32320506': 1, '32293716': 1, '23219649': 1, '30339549': 1, '17470624': 1, '32280973': 1, '34789437': 1, '30427933': 1, '32191813': 1, '31064802': 1, '12493078': 1, '23688302': 1, '24552321': 1, '34602603': 1, '29208005': 1, '32312646': 1, '20046114': 1, '32250385': 1, '23886842': 1, '32345343': 1, '17885261': 1, '29023260': 1, '27940276': 1, '31768568': 1, '34953756': 1, '30113379': 1, '28847238': 1, '33492400': 2}
{'7665777-1': 2, '7665777-2': 2, '7665777-3': 2, '7665777-4': 2, '7665777-5': 2, '7665777-6': 2, '7665777-8': 2, '7665777-9': 2, '7665777-10': 2, '7665777-11': 2}
7
7665777-8
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
This 33-year-old female patient had typical COVID-19 symptoms such as high fever, dry cough, headache, and dyspnea about 1 week before ICU admission. She was intubated and proned due to rapid respiratory deterioration. For the following 6 days, her situation was unstable, and physical therapy consisted of prone positioning and prevention of secondary damage. From day 7 onwards, she started to improve rapidly and could be mobilized passively into a side-edge position. After extubation, she presented postextubation dysphagia and severe ICU-acquired weakness (MRC-SS 36/60). She also suffered from pronounced delirium and anxiety and said repeatedly that she had been abducted and that she believed she had to die. She seemed to feel threatened by us and it was difficult to calm her down. Due to the pandemic measures of the Swiss government, hospital visits were not generally allowed, but because her anxiety was limiting her rehabilitation, her husband was granted an exceptional permission to visit her. This seemed to give the patient a short sense of security, and she started to participate in some basic functional activities (CPAx 21/50). Nevertheless, the delirium did not resolve upon her transfer to a peripheral acute hospital.
[[33.0, 'year']]
F
{'32320506': 1, '32293716': 1, '23219649': 1, '30339549': 1, '17470624': 1, '32280973': 1, '34789437': 1, '30427933': 1, '32191813': 1, '31064802': 1, '12493078': 1, '23688302': 1, '24552321': 1, '34602603': 1, '29208005': 1, '32312646': 1, '20046114': 1, '32250385': 1, '23886842': 1, '32345343': 1, '17885261': 1, '29023260': 1, '27940276': 1, '31768568': 1, '34953756': 1, '30113379': 1, '28847238': 1, '33492400': 2}
{'7665777-1': 2, '7665777-2': 2, '7665777-3': 2, '7665777-4': 2, '7665777-5': 2, '7665777-6': 2, '7665777-7': 2, '7665777-9': 2, '7665777-10': 2, '7665777-11': 2}
8
7665777-9
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
This 66-year-old male patient was admitted to the hospital due to an ischemic left-hemispheric stroke in addition to a dry cough and fever. He tested positive for SARS-CoV-2 the following day but continued to deteriorate resulting in severe ARDS, intubation, and ICU admission. Despite repeated proning, gas exchange did not improve sufficiently and the patient was placed on veno-venous extracorporeal membrane oxygenation for 7 days. After sedation was stopped, the patient continued to be somnolent and unable to communicate or to follow commands. Physical therapy therefore focused on perception training, movement exercises, airway-clearing techniques, dysphagia therapy, and mobilization. A first SOEB trial had to be discontinued due to hemodynamic instability. Instead, the patient was positioned in a side-edge position (), which he tolerated better and where an intensive exercise training including trunk and head control was conducted. Nevertheless, muscle tone and strength remained severely reduced, particularly on his hemiplegic side, and a second SOEB trial failed again. Physical therapy was also limited because of reduced self-activity and suspected impaired perception and visual acuity. Consequently, occupational therapy was involved to create a basis of communication, to support functional initiation of upper limb movements, and to integrate perception-training into activities of daily living. Currently, the patient tolerates spontaneous breathing trials, shows signs of being alert during therapy, but cannot communicate. He is hemodynamically stable, even in an SOEB position, but remains functionally dependent (CPAx 6/50).
[[66.0, 'year']]
M
{'32320506': 1, '32293716': 1, '23219649': 1, '30339549': 1, '17470624': 1, '32280973': 1, '34789437': 1, '30427933': 1, '32191813': 1, '31064802': 1, '12493078': 1, '23688302': 1, '24552321': 1, '34602603': 1, '29208005': 1, '32312646': 1, '20046114': 1, '32250385': 1, '23886842': 1, '32345343': 1, '17885261': 1, '29023260': 1, '27940276': 1, '31768568': 1, '34953756': 1, '30113379': 1, '28847238': 1, '33492400': 2}
{'7665777-1': 2, '7665777-2': 2, '7665777-3': 2, '7665777-4': 2, '7665777-5': 2, '7665777-6': 2, '7665777-7': 2, '7665777-8': 2, '7665777-10': 2, '7665777-11': 2}
9
7665777-10
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
A 66-year-old male started to present symptoms of fever, dyspnea, coughing, asthenia, lack of appetite, nausea, and vomiting. He was admitted to the acute care unit for observation and oxygen therapy, but his oxygen requirements constantly increased due to moderate ARDS. After 12 days of deep sedation, neuromuscular blocking agents, and proning with daily passive range of motion, the patient finally started to initiate active movements and was passively transferred to a chair. However, due to a persisting difficult weaning status, probably related to respiratory muscle weakness, tracheostomy was performed [ventilator settings: pressure support 10 cmH2O, positive end-expiratory pressure (PEEP) 8 cmH2O]. Subsequently, the patient showed significant improvement in his physical functions with active SOEB, chair-transfer with the help of 2 physical therapists, and active in-bed cycling against resistance for 20 minutes (). The strategy was to increase pressure support (by 5 cmH2O) during efforts to reinforce exercise training effects, unloading respiratory muscles. This strategy along with a highly collaborative patient culminated in his rapid improvement in physical function (MRC-SS 58/60, physical function ICU test score 10/12, walking distance 10 m), although he was still experiencing fatigue, inspiratory muscle weakness (maximal inspiratory pressure of −45 cmH2O) and dysphagia upon his transfer to a step-down unit.
[[66.0, 'year']]
M
{'32320506': 1, '32293716': 1, '23219649': 1, '30339549': 1, '17470624': 1, '32280973': 1, '34789437': 1, '30427933': 1, '32191813': 1, '31064802': 1, '12493078': 1, '23688302': 1, '24552321': 1, '34602603': 1, '29208005': 1, '32312646': 1, '20046114': 1, '32250385': 1, '23886842': 1, '32345343': 1, '17885261': 1, '29023260': 1, '27940276': 1, '31768568': 1, '34953756': 1, '30113379': 1, '28847238': 1, '33492400': 2}
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10
7665777-11
33,492,400
comm/PMC007xxxxxx/PMC7665777.xml
Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series
This 77-year-old male patient was transferred to our ICU 1 week after his COVID-19 diagnosis due to continuing respiratory decompensation requiring intubation. Following the acute phase, with intermittent proning, the patient continued to be hemodynamically unstable and was difficult to wean. Rehabilitation proved challenging under these conditions, and physical therapists had to reevaluate and adapt their interventions daily according to his condition. After 2 weeks, he was tracheotomized and started to improve very slowly. One week after tracheostomy, the patient was able to speak for the first time after a cuff-down trial and with the help of a speaking valve. But the patient spoke only a few words with us and it was often difficult to involve him in exercises. Two days later, he was able to communicate with his relatives via video telephony. This was a very emotional moment for everyone involved, but it improved his communication and he was able to express to his wife that he had no strength left to continue. However, through the family’s active participation in his early rehabilitation process, they were able to reinforce his confidence and motivation. He was discharged to a rehabilitation clinic severely weak (MRC-SS 40/60) and functionally impaired (CPAx 22/50), but continued to progress in slow steps.
[[77.0, 'year']]
M
{'32320506': 1, '32293716': 1, '23219649': 1, '30339549': 1, '17470624': 1, '32280973': 1, '34789437': 1, '30427933': 1, '32191813': 1, '31064802': 1, '12493078': 1, '23688302': 1, '24552321': 1, '34602603': 1, '29208005': 1, '32312646': 1, '20046114': 1, '32250385': 1, '23886842': 1, '32345343': 1, '17885261': 1, '29023260': 1, '27940276': 1, '31768568': 1, '34953756': 1, '30113379': 1, '28847238': 1, '33492400': 2}
{'7665777-1': 2, '7665777-2': 2, '7665777-3': 2, '7665777-4': 2, '7665777-5': 2, '7665777-6': 2, '7665777-7': 2, '7665777-8': 2, '7665777-9': 2, '7665777-10': 2}
11
8674153-1
34,956,745
comm/PMC008xxxxxx/PMC8674153.xml
Deranged Liver Function Tests and Liver Insults in Malnourished Patients: A Report of Two Cases and Literature Review
A 45-year-old female was brought in by ambulance after collapsing at home secondary to a hypoglycemic event (capillary blood glucose of 1 mmol/L with paramedics). She had a history of restrictive AN, binge-purge behaviour, and an old traumatic brain injury, leaving her with memory problems. She was well known to mental health services, having been admitted multiple times to eating disorder centres for nasogastric feeding. She had never smoked in her life and denied any alcohol intake. The patient was on ferrous fumarate, fexofenadine, fluoxetine, ibuprofen, lansoprazole, quetiapine, supplemental vitamins, regular morphine (modified release), and gabapentin.\nOn admission, her blood pressure was 106/85 mmHg, respiratory rate was 20 breaths/minute, heart rate was 64 beats/minute, temperature was 35.1 °C, and capillary blood glucose was 6 mmol/L. Her weight on admission was 37.3 kg (body mass index [BMI] = 12.6). On examination, she was clearly malnourished, cachexic, and dehydrated. The rest of the clinical examination was normal, as shown in Table . Her chest radiograph showed patchy consolidations in the right middle and lower lobes (Figure ). She was prescribed appropriate antibiotics. She was refusing treatment and was deemed to lack the capacity to make that decision. Therefore, Section 5(2) under the Mental Health Act was put in place. She was commenced on oral supplements as per guidance from the dietitian, and then switched to nasogastric feeding.\nOn the night of the second day, she had an episode of decreased consciousness, bradypnoea (RR-6), and hypotension (83/64). Her blood sugar level was 6.6 mmol/L. After receiving Naloxone, her symptoms improved, and her opiates were discontinued. The following day she mentioned right upper quadrant pain. Blood tests showed worsening liver enzymes, as shown in Table . An abdominal ultrasound was performed on the fourth day of admission, which showed multiple small calculi and biliary debris, with gallbladder oedema, and a small amount of peri-cholecystic fluid (Figure ).\nShe was treated for cholecystitis with amoxicillin, clavulanic acid, and clarithromycin, which led to improvement in her inflammatory markers in the following days. She underwent an inpatient magnetic resonance cholangiopancreatography (MRCP) to rule out intra-biliary pathology, which was negative. Subsequently, she was referred to surgeons for consideration of elective laparoscopic cholecystectomy once deemed fit.\nShe had a protracted and difficult admission. Due to the coronavirus disease 2019 pandemic, her transfer to an Eating Disorders Unit proved difficult. By the fourth week of admission, her liver enzymes had improved, as can be seen in Table . Nasogastric feeding was successfully weaned as her weight improved. She was discharged on day 51 to an Eating Disorders Unit weighing 56.4 kg (BMI = 18.1) from her admission weight of 37.3 kg (BMI = 12.6).
[[45.0, 'year']]
F
{'18703853': 1, '22644309': 1, '9510397': 1, '26346046': 1, '18951455': 1, '17610252': 1, '25379300': 2, '17671290': 1, '22170021': 1, '15767533': 1, '14566926': 1, '16520436': 1, '32582446': 1, '18644371': 1, '22986227': 1, '34956745': 2}
{'8674153-2': 2, '4208431-1': 1}
12
8674153-2
34,956,745
comm/PMC008xxxxxx/PMC8674153.xml
Deranged Liver Function Tests and Liver Insults in Malnourished Patients: A Report of Two Cases and Literature Review
A 29-year-old male was brought to the hospital by ambulance after collapsing at home. He was found to be bradycardic and hypoglycaemic with a capillary blood glucose level of 2.3 mmol/L. He had a history of eating and anxiety disorders and was not on any regular medications. On admission, his weight was 37.3 kg (BMI = 11.6). His blood pressure was initially un-recordable but subsequently was recorded to be 104/72 mmHg. His capillary blood glucose level was 4.7 mmol/L, and his Glasgow Coma Scale score was 15/15. On examination, he was noted to be severely malnourished and cachexic. The rest of the clinical examination was normal. LFTs were very abnormal, as shown in Table .\nSince admission, he seemed to lack insight. Due to problems keeping him compliant with medication and intravenous glucose, he had a number of hypoglycaemic events in the first two days of admission. The following day, he was deemed not to have the capacity. He underwent Mental Capacity Assessment and Deprivation of Liberty Safeguards. He was ultimately placed under Mental Health Act 5(2) and was started on nasogastric feeding. His liver enzymes worsened further after the introduction of nasogastric feeding, but we were reassured by a normal non-invasive liver screen and ultrasound.\nHis condition, liver tests, and liver synthetic function improved over the course of his 24-day admission (Table ), but his stay was associated with difficult behaviour. He was eventually discharged to an Eating Disorders Unit.
[[29.0, 'year']]
M
{'18703853': 1, '22644309': 1, '9510397': 1, '26346046': 1, '18951455': 1, '17610252': 1, '25379300': 2, '17671290': 1, '22170021': 1, '15767533': 1, '14566926': 1, '16520436': 1, '32582446': 1, '18644371': 1, '22986227': 1, '34956745': 2}
{'8674153-1': 2, '4208431-1': 1}
13
8674405-1
34,956,746
comm/PMC008xxxxxx/PMC8674405.xml
Goserelin Ovarian Ablation Failure in Premenopausal Women With Breast Cancer
A 36-year-old G4P2 premenopausal woman with a family history of colorectal, hepatobiliary cancers felt an abnormal right breast lump. Diagnostic mammogram and ultrasound showed a hypoechoic lesion in the upper outer quadrant of right breast measuring 14 mm x 13 mm x 18 mm and 5 x 4 mm satellite lesion is noted 6 mm inferior to the dominant mass, BI-RADS 5 highly suggestive of malignancy. Due to concern for multifocal disease, MRI breast with without contrast was done and it showed 2.3 x 1.1 x 2.7 cm irregular-shaped, heterogeneous mass with irregular margins in the upper outer quadrant of right breast, 7 cm from the nipple, 1.2 cm from the skin and there was an additional mass measuring 8 mm x 4 mm x 1.6 cm at 12:00 along with 4 mm lesion, 7 mm from the nipple at 10:00 (Figures (a) and (b)). Right breast biopsy from the dominant lesion showed invasive mammary carcinoma with features of both lobular and ductal carcinoma, Nottingham histological grade 2, estrogen receptor 90%, progesterone receptor 100%, HER2 2+ by IHC but negative by FISH, Ki-67 50%.\nStatus post right breast simple mastectomy and axillary lymph node evaluation. Surgical pathology showed a multifocal invasive mammary carcinoma of the breast with ductal and lobular features, size of largest invasive carcinoma was 55 mm, size of additional invasive foci was 1.5 mm, Nottingham histological grade 2 of 3, low to intermediate nuclear grade DCIS without central necrosis measuring at least 6 mm, margins uninvolved, one benign sentinel lymph node. Pathological staging (m)pT3 (sn)N0. Oncotype DX breast recurrence score of 16 (for patients <50 years of age, benefit from chemotherapy 1.6%). Genetic testing did not reveal any clinically significant mutations. The patient has received adjuvant PMRT 5000 cGy dose, 25 fractions along with 1000 cGy scar boost. Based on TEXT/SOFT data ovarian suppression could be considered in patients with high-risk features. The patient's tumor was multifocal, and the largest lesion measured 5.5 cm. The patient elected against surgical menopause. The patient was started on ovarian suppression with goserelin 3.6 mg every 28 days along with letrozole 2.5 mg once daily.\nSixteen months after initiation of ovarian suppression patient started having a regular menstrual cycle while on goserelin. No medication interaction or missed doses were noted. The patient's BMI was 41.1 and BSA was 2.19 m2. Estradiol was 92 pg/mL and follicle-stimulating hormone (FSH) was 4.3 mIU/mL in the premenopausal range. Few prior case reports showing failure of goserelin ovarian ablation in a premenopausal woman were reported. Given high-risk disease, discussed benefit of continued ovarian suppression plus AIs versus tamoxifen alone, and discussed the role of oophorectomy which results are reliable and prompt reduction in circulating estrogens. The patient was hesitant and wished to wait before the oophorectomy. She was started on triptorelin 3.75 mg IM once every 28 days.
[[36.0, 'year']]
F
{'29510273': 1, '10953134': 1, '30258937': 1, '30651078': 1, '7860418': 1, '21555684': 1, '32616435': 1, '12488405': 1, '10620455': 1, '21541703': 1, '26729430': 1, '17138645': 1, '29863451': 1, '3139467': 1, '25495490': 1, '23958111': 1, '26729437': 1, '34956746': 2}
{}
14
8674458-1
34,956,749
comm/PMC008xxxxxx/PMC8674458.xml
Treatment of Inferior Vena Cava Thrombosis by Endovascular Stenting: A Case Report
The patient was a 62-year-old male with a past medical history of liver cirrhosis secondary to hepatitis C, tobacco use, and post-stent coronary artery disease, who initially came to the hospital for elective left and right heart catheterization as a pre-transplant evaluation. Physical examination showed abdominal distension and diffuse tenderness with the presence of prominent superficial abdominal veins. A computed tomography (CT) scan of the abdomen with contrast was obtained immediately. The CT showed an occlusive thrombus of the IVC extending from the renal veins to the level of the cavoatrial junction. Thrombus was also observed in the portal vein, and multiple subcutaneous varicosities were found. Initially, a plan was made to start the patient on anticoagulation, but because of the patient’s history of advanced cirrhosis, large esophageal varices on recent endoscopy, and thrombocytopenia, we concluded that the patient was not a candidate for anticoagulation. Given that the patient had significant abdominal distention with pain that did not improve even after therapeutic paracentesis; we inserted a stent in the IVC to relieve the patient’s pain as a palliative procedure to improve his quality of life.\nRight internal jugular (IJ) and right femoral vein accesses were obtained for the procedure. A 6F pigtail diagnostic catheter was advanced from the right IJ to the right atrium, and contrast was injected into the right atrium that showed an occluded IVC at the junction of the right atrium. Another pigtail catheter was advanced through the right femoral vein and an inferior venogram was performed that showed the IVC was 100% occluded 2 cm above the renal veins (Figures , ).\nA Glidewire advantage was advanced through the right femoral vein but was unable to cross the 100% occluded IVC. Then, a 7-French Swan-Ganz catheter was tried and was successfully advanced through the IVC all the way to the right atrium. A Swan wire was inserted through the Swan-Ganz catheter. Then, a multipurpose catheter was advanced over the Swan wire into the right atrium, and the Swan-Ganz wire was successfully replaced with a Glidewire Advantage (Figure ). Initially, a 9 × 80 Mustang balloon was used to perform the IVC ballooning; after IVC ballooning; however, the inferior venogram showed no flow to the IVC, which was still 100% occluded. Then, a 22 × 70 mm Wallstent was advanced via the right femoral vein to the right atrial side. The stent was deployed with a considerable waist in the mid area (Figure ). After stent placement, an 18 × 60 Boston Scientific esophageal balloon was successfully used to post-dilate the stent (Figure ).\nThe final venogram (Figures , ) and digital subtraction imaging mode showed excellent flow in the IVC to the right atrium. Small clots floating around at the lower edge of the stent above the renal artery were successfully removed with a 7-Fr snare. Usually, if IVC occlusion is of thrombosis in etiology anticoagulation is advised after venous stent placement, since our patient had an advanced liver failure with elevated INR, anticoagulation was not started [].
[[62.0, 'year']]
M
{'29396156': 1, '185006': 1, '15696057': 1, '28797661': 1, '11517106': 1, '34956749': 2}
{}
15
8674685-1
34,956,752
comm/PMC008xxxxxx/PMC8674685.xml
Unusual Cutaneous Location of Langheransian Histiocytosis: A Case Report
We report a case of a 45-year-old woman, a non-smoker, treated for type II diabetes under insulin and primary hyperparathyroidism. Her medical history dates back to 2006 with an infiltrated nodule associated with ulcers that grew gradually in her right thigh. The patient underwent surgery with an anatomopathological study. Skin biopsy objectified ulcerated epidermotropic dermo-hypodermal tumor proliferation whose morphological appearance and immunohistochemical data are in favor of LCH. Langerhans cells present positivity of the anti-PS100 antibody, anti-CD1a antibody, and anti-Ki67 antibody (60%), and negativity of the anti-CD68 antibody. The patient subsequently received 25 sessions of radiotherapy followed by six courses of chemotherapy with a low dose of oral methotrexate. After these treatments, skin lesions are stable. In 2020, the patient complained of an increase in skin lesions, with the appearance of several infiltrating nodules, scaling, crusted papules, and ulcerated plaques. The patient received chemotherapy as single-system LCH (SS-LCH) based on methotrexate, associated with prednisone and vinblastine, with the obtainment of stable response and limited regression of the lesions. After two courses, the patient was lost to follow-up. One year later, the oncologist referred the patient to the hematology department for a major increase in skin lesions, with the appearance of new ones on her thigh. Dermatological examination found ulcers and necrotic lesions, purplish, well-limited, of variable size, not painful, not warm to the skin, and localized to the right thigh. The mucous membranes and integuments were unharmed (Figure ).\nFurthermore, the examination found an afebrile, obese patient (body mass index (BMI) at 44.8). Abdominal and cardiovascular examinations were unremarkable. The physical examination did not find any tumoral syndromes, and the patient did not present have B signs (fever, weight loss, and night sweats). A complete assessment was carried out in favor of a cutaneous location without visceral involvement. A CT scan of the chest and abdomen was normal. Extensive investigation revealed no systemic involvement, central nervous system (CNS) evaluation was not done, serum thyroid hormone levels were normal, endocrine workup was performed, including cortisolemia, and parathormone assessment were done in favor of primary hyperparathyroidism. A skin biopsy was performed. The microscopic examination revealed a cutaneous tissue with an infiltrate of large cells involving the dermis and realizing an epidermotropism. The infiltrate was composed of atypical cells with abundant, pale eosinophilic cytoplasm, irregular and elongated or lobed nuclei with prominent nuclear grooves and folds, fine chromatin, and indistinct nucleoli. Multinucleated giant tumor cells, high cytonuclear atypia, and marked nuclear pleomorphism were seen. The mitotic figures were increased. The neoplastic cells also showed a mixed inflammatory background with variable numbers of reactive lymphocytes, plasma cells, benign histiocytes, and eosinophils associated (Figure ).\nThe immunohistochemical stains had shown a diffuse strong and heterogeneous positivity for CD1a and S100 and variable positivity for CD45. All other markers studied were negative, including CD68, cytokeratins (AE1/AE3), and melanocytic marker (MelanA). The Ki-67 proliferation index was high (50%) (Figure ).\nIn the light of microscopic and phenotypic results, the diagnosis of Langerhans cell sarcoma was confirmed. The patient did not receive any maintenance therapy and she received only two courses of chemotherapy; consequently, the patient was included in the LCH protocol as single-system LCH (SS-LCH), and she received the same chemotherapy combining prednisone (60 mg / m2), high-dose of methotrexate (5000 mg/m2), and vinblastine (10 mg/m2). The evolution was favorable after five cycles of chemotherapy with significant regression of lesions in the thigh without the appearance of any new lesions (Figure ).
[[45.0, 'year']]
F
{'30281871': 1, '9611381': 1, '26966089': 1, '20465678': 1, '7501855': 1, '27816338': 1, '26461147': 1, '32845598': 1, '24514957': 1, '27081283': 1, '20519626': 1, '22879539': 1, '34956752': 2}
{}
16
8675570-1
34,956,761
comm/PMC008xxxxxx/PMC8675570.xml
Bilateral Ureteral Obstruction Causing Acute Kidney Injury and Resultant Metformin Toxicity
We describe the case of a 55-year-old male who presented to the emergency department via emergency medical services for the chief complaint of sudden onset shortness of breath that woke him from his sleep just prior to arrival. He reported three days of non-radiating lumbar back pain and two episodes of non-bloody emesis leading up to this event. His medical history included hypertension and type 2 diabetes mellitus. His current medications were metformin, amlodipine, losartan, and atenolol. Initial vital signs revealed heart rate (HR) 75, respiratory rate (RR) 29, blood pressure (BP) 119/62, and oxygen saturation 99% on 2L nasal cannula. Temperature was 36.3°C.\nPhysical examination was significant for an ill-appearing male patient who was anxious and tachypneic. He also had significant work of breathing with retractions and abdominal breathing. Lungs were clear to auscultation, with no wheezing, rhonchi, or rales. Abdominal exam revealed mild epigastric tenderness with no rebound, guarding, or palpable pulsatile mass. No costovertebral angle (CVA) tenderness or midline tenderness was elicited. Neurological exam revealed no focal deficits.\nDue to his presentation and multiple comorbidities we had significant concern for the possible acute coronary syndrome, dissection, sepsis, or pulmonary embolism. Blood work including complete blood count (CBC), comprehensive metabolic panel (CMP), lactic acid, troponin, urine analysis (UA) was ordered. CT-angiogram of his chest, abdomen, and pelvis was also ordered.\nComplete blood count revealed a white blood cell count of 20.4 x 103/uL, hemoglobin of 11.2 g/dL, and platelet count of 376 x 103/uL. Comprehensive metabolic panel was significant for a sodium of 145 mmol/L, potassium 6.1 mmol/L, chloride 100 mmol/l, bicarbonate <7 mmol, blood urea nitrogen (BUN) 67 mg/dl, creatinine 14.7 mg/dL, calcium 9.1 mg/dL, and glucose of 165. Troponin I was <0.012 ng/mL. Initial lactic acid was recorded at 13.9 mmol/L. An arterial blood gas revealed severe anion gap metabolic acidosis with a pH of 6.9, pCO2 of 22.3 mmHg, pO2 of 105.5 mmHg, HCO3 of 5.3 meq/L, and a Base Excess of -24.8 mmol/l. The patient was anuric at this time. Initial EKG showed normal sinus rhythm (NSR), nonspecific ST abnormalities, vent rate 73, QTC 471. The CT scan revealed an obstructing stone at the left proximal ureteropelvic junction (Figures , ) and at the right ureterovesical junction (Figure ), with resultant bilateral hydronephrosis (Figure ).\nWhile in the ED the patient progressively became hypotensive and was given broad-spectrum antibiotics, Vancomycin and Cefepime, due to concern for sepsis and aggressive fluid resuscitation was initiated. The patient did not respond to fluid resuscitation and was started initially on Levophed. In addition, the patient received 100 mL of 8.4% sodium bicarbonate and 2 grams of calcium gluconate for severe metabolic acidosis and hyperkalemia. Due to the expected clinical decline, the patient was intubated in the emergency department. Critical Care, Nephrology, and Urology were consulted emergently in the ED. After initial stabilization, the patient was taken for immediate bilateral percutaneous nephrostomy (PCN) placement by Interventional Radiology (IR) and placement of a trialysis catheter for initiation of hemodialysis afterward. Urinalysis from the PCN revealed hematuria, but no evidence of infection.\nAfter successful placement of bilateral PCN, the patient was transferred to the intensive care unit (ICU) in critical condition. He was maintained on multiple vasopressors consisting of combinations of norepinephrine, vasopressin, epinephrine, and phenylephrine along with stress dose hydrocortisone. Repeat blood gas and labs revealed a worsening metabolic and lactic acidosis with a repeat pH of 6.7 and a lactic acid of 15.9. The patient was started on hemodialysis with a high bicarbonate dialysate for emergent clearance of hyperkalemia and refractory acidosis. After hemodialysis, the patient’s pH was 7.1, despite a worsening lactic acidosis of 17.0 mmol/L. Overnight the patient was converted to continuous venous-venous hemodialysis, a form of continuous renal replacement therapy (CRRT). Within 24 hours the patient’s acidemia corrected and blood pressure stabilized allowing for a de-escalation of vasopressors. A repeat chemistry revealed recovering renal function along with urine production in the nephrostomy tubes. On hospital day 3, the patient was successfully extubated, weaned off all vasopressors, and CRRT was stopped. Blood and urine cultures taken prior to dialysis were negative after five days. On hospital day 6, Urology performed a cystoscopy with bilateral ureteral stent placement and removal of bilateral percutaneous nephrostomy tubes. On hospital day 8, the patient had made a remarkable recovery from being critically ill. His creatinine was 1.5, BUN 27, and he was discharged home with urology follow-up in 1-2 weeks.
[[55.0, 'year']]
M
{'26800971': 1, '27030462': 1, '24251430': 1, '26981442': 1, '25215151': 1, '25860205': 1, '22154632': 1, '22722338': 1, '26773926': 1, '32382466': 2, '31842973': 2, '25552792': 1, '22517736': 1, '31598437': 2, '34956761': 2}
{'7202579-1': 1, '6916532-1': 1, '6777935-1': 1}
17
8675571-1
34,956,751
comm/PMC008xxxxxx/PMC8675571.xml
De-novo Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Following the mRNA-1273 (Moderna) Vaccine for COVID-19
A 58-year-old Caucasian (American) male with an unremarkable past medical history presented for evaluation of nausea, vomiting, and a 30-pound weight loss over the past two months at our hospital. He also reported dark-colored urine and intermittent episodes of hemoptysis during the same period. Specifically, he stated that his symptoms started four days after receiving his second dose of the mRNA-1273 (Moderna) vaccine for COVID-19. His first dose taken three weeks earlier was well tolerated. He denied any flank or abdominal pain, melena, fever, cough, hematuria, urinary frequency or urgency, and trauma. He denied smoking. Vital signs were stable upon admission. Physical examination was insignificant for any lower extremity pitting edema, petechiae, or rash. The patient was not on any medication prior to his hospitalization.\nLaboratory analysis was remarkable for serum creatinine of 4.1 mg/dL (0.8-1.4 mg/dL) along with hematuria and sub-nephrotic proteinuria of 1796 g/24 hours (<150 mg/24 hours). Our differential diagnosis at this point was wide including all nephritic syndromes given AKI, hematuria and proteinuria. All serological workup was subsequently sent. C-ANCA (anti-neutrophil cytoplasmic antibodies) were elevated 160 AU/mL (20-25 AU/mL) and anti-proteinase 3 (anti-PR3) antibodies were also elevated >100 EU/ mL (normal <3.5 EU/mL) (Table ). Immunohistochemical staining for the SARS-CoV-2 spike protein was not performed. All previous routine laboratory parameters including urinalysis were within normal range.\nHe underwent computed tomography (CT) scan of the chest for evaluation of hemoptysis that showed a right upper lobe consolidation and moderate bilateral pleural effusion.\nThe renal ultrasound was unremarkable. Renal biopsy was subsequently performed and showed acute, pauci immune, focal necrotizing, and diffuse crescentic glomerulonephritis (Figures , ).\nThe patient was diagnosed with anti-PR3-associated ANCA glomerulonephritis. He received intense immunosuppression with plasma exchange x 5 cycles, intravenous prednisone 1 gram x 3 doses followed by prednisone 60 mg daily, cyclophosphamide x 2 doses, and rituximab x 4 doses. The patient achieved remission after 10 weeks of diagnosis with a resolution of symptoms and improvement in renal function with a creatinine of 1.5 mg/dl. He is following in our nephrology office regularly since discharge.
[[58.0, 'year']]
M
{'34659268': 2, '33378609': 1, '34081948': 1, '18077783': 1, '33332890': 1, '34100115': 1, '34280507': 1, '34087251': 1, '32563547': 1, '33882225': 1, '34416184': 1, '17602941': 1, '34423176': 1, '32839744': 1, '26361945': 1, '33301246': 1, '23941822': 1, '34956751': 2}
{'8514980-1': 1}
18
8675572-1
34,956,768
comm/PMC008xxxxxx/PMC8675572.xml
Metastatic Endometrial Cancer to the Sigmoid Colon Masquerading as Primary Colorectal Cancer
A 67-year-old Caucasian female presented to our hospital with a chief complaint of persistent bright red blood per rectum. Her medical history was significant for hypertension, hyperlipidemia, diabetes mellitus type 2, coronary artery disease with three prior myocardial infarctions, recurrent cerebrovascular accidents requiring anticoagulation with warfarin, gastroesophageal reflux disease, asthma, and endometrial cancer status post radiation therapy. Fifteen months prior to the current presentation, the patient was noted to have a grade 1 endometrial adenoma but was not considered a good surgical candidate due to multiple comorbidities. Vaginal hysterectomy was considered but due to her long and narrow vagina, this option was deferred initially. Her only treatment option was radiation therapy and brachytherapy. She eventually underwent total abdominal hysterectomy with bilateral salpingo-oopherectomy due to continued pelvic pain. The patient denied any prior history of gastrointestinal (GI) bleeding. Her bleeding was described as one large episode of bright red blood per rectum associated with blood clots. She denied any abdominal pain, nausea, vomiting, diarrhea, constipation, or melena. The most recent colonoscopy was performed four months ago and revealed three diminutive polyps in the transverse colon with pathology confirming tubular adenoma.\nHer physical examination was significant for mild left-sided abdominal tenderness but was otherwise unremarkable. Rectal examination was notable for nonbleeding hemorrhoids and no visible blood. Blood work revealed white blood cells of 14.3k/uL (normal range 4.3-10.0 k/uL) and hemoglobin of 9.6 g/dL (normal range 11.8-14.8 g/dL), which is similar to the patient’s baseline. Creatinine was slightly elevated to 1.2 and blood urea nitrogen was elevated to 39. International normalized ratio was 2.0. Due the large volume of hematochezia and presence of anemia, the patient was admitted to the hospital and underwent a colonoscopy, which revealed a large, fungating, friable, and ulcerated nonobstructing mass in the sigmoid colon. The mass was noncircumferential, measured 4 cm in length, and was located 15-19 cm from the anal verge (Figures , ). Biopsies were obtained with cold forceps for histology and the proximal and distal margins of the mass were tattooed. Histology showed invasive and moderately differentiated carcinoma without visible goblet cells. Given the patient’s history of endometrial cancer, immunohistochemistry was performed and was consistent with an endometrial (endometrioid subtype) primary.\nPan-computed tomography was negative for any obvious distant disease. The tumor marker carcinoembryonic antigen level was normal as well. The patient subsequently underwent surgical resection of the affected colon followed by radiation therapy. At a follow-up visit one year later, the patient was doing well without active GI complaints.
[[67.0, 'year']]
F
{'21380941': 1, '33433946': 1, '11007036': 1, '33383960': 1, '29209543': 2, '34956768': 2}
{'5676375-1': 1}
19
8675574-1
34,956,758
comm/PMC008xxxxxx/PMC8675574.xml
An Approach for Diagnosing and Treating Neurosyphilis: A Case Report
A 71-year-old African American female with a medical history of hypertension, type 2 diabetes mellitus, stage 3 chronic kidney disease, and osteoarthritis initially presented to the emergency room with intermittent bilateral hand tingling and numbness, which was gradual in onset over months. Her symptoms were associated with seeing red spots and experiencing a burning sensation in the bottom of her feet. She was concerned because she was having difficulty picking up objects due to her hand symptoms. Her basic lab work was unremarkable, and she was provided gabapentin and magnesium oxide with close follow-up with her primary care physician. At follow-up, she complained of one to two months of unsteady gait as well as increased confusion. Her reported medications included losartan and metformin. Physical exam revealed normal pupils with reaction and accommodation (3mm diameter bilaterally), no cranial nerve deficits, normal strength throughout, and normal reflexes throughout except for diminished reflexes in the bilateral knees and ankles. She endorsed blurry vision; no ophthalmologic exam was performed, but she was able to read a name badge from one foot away. She additionally was found to have decreased vibratory and proprioception in a stocking pattern as well as a wide-based and unsteady gait.\nTo investigate further, tests for thyroid-stimulating hormone (TSH), folate, B12, and rapid plasma regain (RPR) titer were ordered. Her TSH, folate, and B12 levels were within normal limits, but her RPR titer was reactive at 1:1. A subsequent reflex Treponema pallidum particle agglutination (TP-PA) test was reactive. She was told to go to the hospital for further workup and treatment. Further questioning revealed that she had had two sexual partners in her life, both ex-husbands. However, she noted that her husbands committed adultery several times and that she was not currently sexually active; her last sexual encounter occurred several years ago. She endorsed that she did not notice any ulcers or skin lesions, and she had not been treated for syphilis. During hospitalization, she received a lumbar puncture that revealed a negative venereal disease research laboratory (VDRL) test result. Her glucose level (61 mg/dL) and white blood cell level (3 x 109/L) were normal, but her CSF protein level was markedly elevated at 156 mg/dL. Due to her exposure history, a constellation of symptoms, RPR titer with positive TP-PA, and protein elevation in her CSF, our infectious disease colleagues believed that she contracted syphilis earlier in life from one of her husbands and was never treated. The decision was made to start treatment with intravenous (IV) penicillin (24 million units, continuous infusion) for two weeks. At follow-up, her vision had improved and she no longer had sensory symptoms in her hands. Her gait was somewhat improved, but still unsteady, and she still had burning pain in her feet. Her physical exam showed improvement in sensation in hands and improved gait; all other neurological exam was unchanged. It was thought that neuropathy in feet could have been due to poorly controlled diabetes; although, no formal nerve conduction study was pursued.
[[71.0, 'year']]
F
{'31577877': 1, '15477572': 1, '25387188': 1, '29986091': 1, '34956758': 2}
{}
20
8675577-1
34,956,771
comm/PMC008xxxxxx/PMC8675577.xml
An Extremely Rare Case of Metastatic Merkel Carcinoma of the Liver
Our patient is a 78-year-old male with a past medical history of cutaneous T-cell lymphoma/mycosis fungoides (on regular outpatient extracorporeal photopheresis), type II diabetes mellitus, atrial flutter on Xarelto, and sick sinus syndrome on dual-chamber pacemaker, presented to the hospital with right upper quadrant abdominal pain. The patient was a former smoker and denied any alcohol use.\nIn the emergency department, he was hemodynamically stable. Laboratory workup was significant for abnormally elevated liver function tests including aspartate aminotransferase/alanine aminotransferase (AST/ALT) of 204/188 U/L, alkaline phosphatase (ALP) of 550 U/L, and total bilirubin of 2.5 mg/dL. Ultrasound of the abdomen was negative for any focal liver or gallbladder lesions. There was no evidence of intrahepatic or extrahepatic biliary duct dilation. Hepatobiliary iminodiacetic acid (HIDA) scan was normal, and hence cholecystitis was ruled out. CT abdomen and pelvis and CT angiography of the chest were negative for acute pathology. As the patient had a pacemaker, magnetic resonance cholangiopancreatography (MRCP) could not be performed. Further laboratory evaluation for elevated liver enzymes, including viral hepatitis panel, thyroid-stimulating hormone (TSH), iron panel, antinuclear antibody (ANA), anti-mitochondrial antibody, alpha-1-antitrypsin antibody, anti-smooth muscle antibody, and ceruloplasmin was negative.\nGiven that the patient has a history of cutaneous T-cell lymphoma, the important differential diagnosis included leukemic infiltration of the liver and adverse reaction to the prior chemotherapy. However, the patient received only a short course of the chemotherapeutic regimen mogamulizumab (due to insurance issues), and hence it was unlikely to cause this current clinical picture. Subsequently, a percutaneous liver biopsy was performed to confirm the diagnosis, which showed replacement of the normal liver parenchymal cells by high-grade tumor cells with a high nuclear-cytoplasmic ratio (Figures -). The tumor cells showed positive immunohistochemical staining for cytokeratin AE1/AE3, cytokeratin 20 (CK20), synaptophysin, chromogranin, and negative for CK7, caudal type homeobox transcription factor 2 (CDX-2), and thyroid transcription factor 1 (TTF-1) (Figures -). All these features were suggestive of metastatic Merkel cell carcinoma. There was no evidence of leukemic infiltrates. As the patient had no evidence of MCC involvement of the skin, he was diagnosed with metastatic MCC of the liver of unknown primary.\nHematology/Oncology and Dermatology was consulted. Considering the medical comorbidities, the patient and family opted for comfort care measures and were discharged home.
[[78.0, 'year']]
M
{'25765179': 1, '32324435': 1, '16896047': 1, '28097368': 1, '26286197': 1, '31084721': 1, '27592805': 1, '29072302': 1, '19000060': 1, '20424236': 1, '23576560': 1, '27093365': 1, '11992403': 1, '6344978': 1, '29102486': 1, '28350180': 1, '18280333': 1, '26257075': 1, '34956771': 2}
{}
21
8675578-1
34,956,744
comm/PMC008xxxxxx/PMC8675578.xml
Multiple Sclerosis Masquerading as Post Septorhinoplasty Complication: A Case Report
A 24-year-old healthy woman presented with difficulty breathing and dissatisfaction with her facial appearance. She had a history of childhood trauma resulting in nasal septum deviation and external nasal deformity. Four months after a successful and uneventful septorhinoplasty, she presented to the emergency department with blunt nasal trauma resulting in a septal hematoma, which was drained successfully; the patient was discharged with no adverse sequelae.\nFour months later, the patient sustained nasal trauma again, this time accompanied by clear nasal discharge, raising suspicion of cerebrospinal fluid (CSF) leak. The patient was discharged after managing the nasal injury, as the CT brain showed an intact cribriform plate with no evidence of a CSF leak. Ten days later, she presented at the emergency department with dizziness and an unstable gait. She also had complaints of paresthesia for the past two months, beginning in her right hand and progressing to the right shoulder, arm and leg, associated with some difficulty in the execution of movements in the first and second finger of the right hand. Her right leg was quite stiff with difficulty in walking. On close inquiry, she gave history of pain in the right eye and double vision many months back, which had resolved spontaneously. Examination showed a positive Romberg’s and Lhermitte’s sign, with right-sided sensory impairment.\nMagnetic resonance imaging (MRI) of the brain, cervical and thoracic spine demonstrated demyelinating lesions in the brain and cervical segment of the spinal cord (Figure ). Some of the lesions demonstrated enhancement on post gadolinium administration sequences, suggestive of active demyelinating diseases like MS. A lumbar puncture was performed which demonstrated the presence of oligoclonal bands in the CSF. The diagnosis of MS was confirmed by a neurologist and treatment was initiated.\nThe initial neurological symptoms have largely vanished with only persistent light paresthesia in the right hand. Two years later she has had no new symptoms and continues with the same medication with good tolerance.
[[24.0, 'year']]
F
{'23419563': 1, '8413941': 1, '30300457': 1, '24246497': 1, '29770875': 1, '23772326': 1, '29377008': 1, '34956744': 2}
{}
22
8675583-1
34,956,755
comm/PMC008xxxxxx/PMC8675583.xml
Upper Urinary Tract Urothelial Carcinoma With Squamous, Glandular, and Sarcomatoid Variants in a Horseshoe Kidney: A Novel Case Report and Literature Review
A 64-year-old Caucasian male smoker with a horseshoe kidney with a history of open pyelolithotomy 18 years ago, presented to King Abdulaziz Medical City in mid-2020 with a report from another hospital stating that he developed gross hematuria six months prior, which was treated as a urinary tract infection. A CT of the abdomen and pelvis was performed in that hospital, showing a horseshoe kidney with severe left hydronephrosis and enlarged retroperitoneal lymph nodes, with the largest one located in the posterior part of the left renal artery measuring 4.7 × 3.5 × 2.6 cm. Additionally, there were multiple stones (Figures , , ). Urine culture was performed and revealed that various organisms were isolated (10-100,000 CFU/ml). Urinalysis showed a small amount of blood with a moderate presence of leukocytes and a trace protein.\nAt the end of 2020, the patient underwent magnetic resonance imaging (MRI). The MRI showed a horseshoe kidney with chronic hydronephrosis of the left kidney and a large mass within it centrally with further satellite lesions, which all likely represent UC and associated lymphadenopathy along the para-aortic chain (Figure ). Additionally, a finding of chronic pancreatitis was noted with dilated duct and stone, for which the patient was referred to the gastroenterology department. Furthermore, a bone scan and chest CT were performed, and no significant abnormality or metastasis was found.\nAfter a couple of days, the patient presented to the emergency department with non-radiating progressive lower abdominal and left colicky flank pain for three days with hematuria and constipation with fullness. The patient denied any history of fever or vomiting. There were no other genitourinary symptoms, scrotal pain, or change in the level of consciousness. Vital signs were measured and were as follows: blood pressure, 151/71 mmHg; heart rate, 109; respiratory rate, 20; and temperature, 37.1℃. The weight of the patient was 48.4 kg, and height was 166 cm. The chest was clear, while the abdomen was tender over the left side and the left flank area. Lab results were obtained (Table ). Urine culture was performed and showed more than 100,000 CFU/ml of Staphylococcus aureus being isolated. Abdomen and pelvis CT was performed to rule out any intra-abdominal collections, but it was negative. The urology team was consulted for his chief complaint, as his case is already known to them. On examination, they found that the abdomen was soft with lower left quadrant tenderness. They concluded that the pain was less likely to be from the left kidney as the CT findings were stable. Furthermore, based on the urine culture result, the patient was prescribed Bactrim and was given an appointment for admission a week later to perform a flexible ureteroscopy with biopsy.\nAfter one week, the patient underwent ureteroscopy with cytology and culture based on his MRI findings. Cystoscopy and retrograde pyelography showed normal bilateral ureters. However, the left kidney was severely dilated, and cloudy urine was noticed from the left ureteric orifice. Thus, culture and cytology were taken; then, a double-J (DJ) stent was inserted (Figure ). Urine culture was positive for S. aureus, and the patient was already on Bactrim. The urine cytology result was negative for high-grade UC, but benign urothelial cells, squamous cells, inflammatory cells, and red blood cells were present. Furthermore, since cancer could not be excluded, the patient was discharged and given an appointment for a left nephroureterectomy.\nAfter two weeks, the patient presented to the emergency room complaining of left flank pain for five days with hematuria and constipation. The urology team was again consulted and suspected urinary tract infection at the site of the double J stent. Thus, the patient was admitted, given antibiotics, and was planned for the open left radical nephroureterectomy the following day. The surgery was successfully performed, and samples were sent to the histopathology department.\nMacroscopic examination showed a fairly-circumscribed, bulging, gray-white mass located mainly in the renal pelvis and mostly replacing the entire kidney. It measured 14 cm in maximum dimension. The mass cut sections were homogenous with areas of necrosis, with a stent present (Figure ). The mass is away from margins and Gerota’s fascia by 2 cm. The remaining kidney parenchyma showed dilated cystic spaces containing multiple brownstones. Furthermore, the resected left renal hilum lymph node measured 7 cm in maximum dimension. Microscopically, the tumor showed urothelial carcinoma of the renal pelvis with dysplasia in the background. In addition, the tumor had a predominance of sarcomatoid differentiation. Furthermore, foci of squamous formation containing keratin formation, and other foci of glands with mucinous and goblet cells lining were seen. The tumor was focally extending to the perinephric fat. Margins were negative; however, the ureteric margin showed dysplasia. The left renal hilum lymph node was positive for metastatic carcinoma. The final diagnosis based on the examination was UC of the renal pelvis with sarcomatoid differentiation (70%) and unusual histological differentiation including squamous (25%), and glandular (<5%) (Figure ). In addition, there was no outside pathology confirmation done. Immunohistochemistry profile was positive for CK7, epithelial membrane antigen (EMA), vimentin, and focally for smooth muscle antigen (SMA). However, it was negative for desmin, cytokeratin (AE1/3), and GATA-3 (Figure ).\nAccording to the American Joint Committee on Cancer (AJCC), the pathological stage is pT3N2Mx. After a couple of days, the patient underwent a cystourethrogram, and there was no leak. The patient was eventually discharged in good health the next day and was given an appointment. The plan of the oncology team was to start adjuvant chemotherapy and perform positron emission tomography-CT (PET-CT) for the suspicious distant lymphadenopathy. In addition, CT, cystoscopy, and urine cytology were supposed to be done regularly. However, the patient missed the appointment, so the current status of the patient is unknown.
[[64.0, 'year']]
M
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{'7897460-1': 1}
23
8675589-1
34,956,800
comm/PMC008xxxxxx/PMC8675589.xml
Nitroglycerin as a Treatment Modality for Recurrent Isolated Paracentral Acute Middle Maculopathy: A Case Report
A 47-year-old Caucasian male with a history of an aortic valve replacement, Factor V Leiden anomaly, migraines, and a competitive cycling hobby presented with new paracentral blind spots in the right eye following a fishing trip in Florida on August 28, 2014. The patient reported that the vision loss began during a fishing trip when he became dehydrated and had not resolved. He described three to four similar events that occurred previously following episodes of extreme physical activity, however, all resolving. On presentation in 2016, visual acuity was 20/20 in both eyes. No fundus abnormalities were noted. Amsler grid testing revealed two scotomas about 1 and 4 degrees superior nasal to fixation in the right eye. Spectral-domain OCT imaging also revealed several hyperreflective bands in the middle retina of the right eye (Figure ). In Figure , the hyporeflective lesions seen at the border of the fovea inferior temporal and slightly further out were consistent with his subjective superior nasal scotomas on Amsler grid testing. Spectral-domain OCT findings of PAMM were corroborated with the Chief of the Retinal Service at the New York Eye and Ear Infirmary. The patient was diagnosed with findings consistent with PAMM. At that time, no treatment was given. While diagnostic measures were not taken during this patient’s first few described episodes, it was thought that the previous episodes were also consistent with PAMM, given their similar presentation on the Amsler grid testing and symptomatology.\nIn mid-2018, the patient presented with a left-sided visual scotoma that had developed following a recent episode of febrile gastroenteritis. Treatment started with niacinamide OTC minerals, which helped initially over 30-40 minutes. After consulting with his cardiologist, nitroglycerin was prescribed but not taken. The patient was treated with 325 mg of aspirin and 200 mg of ibuprofen every 4 hours, with minimal relief. Aspirin and ibuprofen were administered because they are anti-inflammatory and blood thinners. The scotoma improved over the course of the next week but did not fully resolve. A permanent small scotoma remained.\nIn 2019, the patient began to experience similar symptoms after vigorous exercise. The patient was treated with 0.4 mg nitroglycerin sublingually previously prescribed by his cardiologist. Within 45 minutes, the visual scotoma improved, and within a few hours, it completely resolved. Since this occasion, the patient experienced two subsequent episodes of the development of visual scotomas, both resolving within minutes of the administration of sublingual nitroglycerin.\nThe patient described the lesions as permanent obstructions in the field of vision. They appear as small opaque structures, with a purple hue. The structures blend into the background without a distinct outline. The right eye lesions seen in Figure appeared at about 11 o’clock in the field of the patient's vision and did not move.
[[47.0, 'year']]
M
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{}
24
8675591-1
34,956,801
comm/PMC008xxxxxx/PMC8675591.xml
A Case of Incidental Detection of Asymptomatic Bladder Cancer by Transvaginal Ultrasound
The patient was a 68-year-old female with a G3P2 (G, gravidity; P, parity) pregnancy history who had undergone a pancreatoduodenectomy of the pancreas to remove a tumor (adenocarcinoma) of the duodenal papillae at our hospital five years ago. She underwent computed tomography (CT) during the postoperative follow-up and was suspected of having an ovarian tumor (Figure ); thus, she visited our Department of Obstetrics and Gynecology. Transvaginal ultrasound showed a mass with abundant internal blood flow in the bladder mucosa (Figure ). Although the patient had no urinary tract symptoms, an examination by a urologist was deemed necessary. Accordingly, the patient was referred to the Department of Urology, and urinalysis and urine cytology were performed because early-stage bladder cancer was suspected. Urinalysis showed no hematuria, but urine cytology showed dysmorphic cells that were indicative of a tumor. Cystoscopy revealed a stalked papillary tumor at the apex of the posterior wall of the bladder. Transurethral resection of bladder tumor was performed the following month. A 2-cm papillary tumor was found at the apex of the bladder (Figure ), and the lesion was resected, followed by intravesical chemotherapy administration. The pathological diagnosis revealed that the removed mass was a non-muscle-invasive bladder tumor (transitional cell carcinoma, stage 0a). At the three-month postoperative follow-up, no recurrence was noted. Postoperative CT examination has not yet been performed.
[[68.0, 'year']]
F
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{'7162668-1': 1, '7162668-2': 1}
25
8675592-1
34,956,798
comm/PMC008xxxxxx/PMC8675592.xml
Bradycardia Related to Remdesivir During COVID-19: Persistent or Permanent?
A 54-year-old Caucasian female, without significant past medical history, unvaccinated for COVID-19 presented with shortness of breath, cough, myalgias, nausea, vomiting, diarrhea, and fevers a week starting with headache. Upon initial evaluation in the emergency room, vital signs were as follows: blood pressure (BP) was 115/77 mmHg, heart rate (HR) was 103 beats per minute (bpm), temperature was 99.0°F, and oxygen saturation was 84% on room air. Lab work showed nasopharyngeal swab positive for SARS-CoV-2, elevated D-dimer (772 ng/mL), elevated international normalized ratio (INR) (1.3), hyperglycemia (117 mg/dL), hyponatremia (130 mmol/L), hypokalemia (3.3 mmol/L), hypochloremia (91 mmol/L), elevated liver enzymes (aspartate aminotransferase {AST}: 157 U/L, alanine aminotransferase {ALT}: 87 U/L), elevated N-terminal pro b-type natriuretic peptide (NT-proBNP) (508 pg/mL), and elevated troponin (13 ng/L). Chest x-ray showed bilateral infiltrates. CT chest with contrast showed bilateral pneumonia. The patient was admitted to the telemetry unit and started on ceftriaxone, azithromycin, dexamethasone, and remdesivir. Initial EKG on admission showed sinus tachycardia and left axis deviation with HR of 101 bpm (Figure ). After three days of remdesivir, EKG was repeated and showed sinus bradycardia with nonspecific intraventricular conduction delay, with HR of 57 bpm (Figure ). Third day after discontinuing remdesivir, the patient developed a transient arrhythmia noted on telemetry which resolved within a few seconds. This prompted nurse to get an EKG which showed normal sinus rhythm (Figure ). Potassium levels were low initially and after repletion potassium normalized on day two of hospital stay. Magnesium levels were normal throughout the hospital stay.
[[54.0, 'year']]
F
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{'8675592-2': 2}
26
8675592-2
34,956,798
comm/PMC008xxxxxx/PMC8675592.xml
Bradycardia Related to Remdesivir During COVID-19: Persistent or Permanent?
A 54-year-old Hispanic female with a past medical history of type 2 diabetes mellitus, unvaccinated for COVID-19 presented with shortness of breath, cough, and pleuritic chest pain for four days. Upon initial evaluation in the emergency room, vital signs were as follows: BP was 118/63 mmHg, HR was 80 bpm, temperature was 103.1°F, and oxygen saturation was 91% on room air. Lab work showed nasopharyngeal swab positive for SARS-CoV-2, leukopenia (WBC: 3.8x103/uL), elevated D-dimer (514 ng/mL), hyperglycemia (126 mg/dL), elevated liver enzymes (AST: 224 U/L, ALT: 175 U/L), elevated c-reactive protein (CRP) (129.8 mg/L), and elevated respiratory procalcitonin (0.26 ng/mL). Chest x-ray showed patchy bilateral lung opacities. CT chest with contrast showed moderate bilateral pulmonary infiltrates. The patient was admitted to the telemetry unit and started on ceftriaxone, azithromycin, and dexamethasone. EKG on admission showed normal sinus rhythm with HR of 80 bpm (Figure ). The day following admission, the patient was started on remdesivir. After two doses of remdesivir, the patient developed severe sinus bradycardia with HR of 30-40 bpm, and remdesivir was discontinued (Figure ). She continued to have bradycardia with HR of 45-60 bpm persistently throughout the hospitalization. Potassium and magnesium levels stayed within normal limits for this patient throughout the hospital stay.
[[54.0, 'year']]
F
{'34322890': 1, '32870481': 1, '32521159': 1, '32445440': 1, '33964035': 1, '33163977': 1, '32547625': 1, '34479903': 1, '30987343': 1, '33091434': 1, '34956798': 2}
{'8675592-1': 2}
27
8675594-1
34,956,772
comm/PMC008xxxxxx/PMC8675594.xml
Leptomeningeal Disease as an Initial Presenting Manifestation in Breast Cancer
A 59-year-old female, current smoker with 20 pack-years history, with a past medical history only significant for hypertension, gradually developed anorexia, nausea, fatigue, and weight loss. She initially presented to the emergency department with left flank pain and on CT scan of the abdomen was found to have diffuse osteosclerotic lesions in visualized bones. She was then followed up in primary care clinic where workup for an occult malignancy was initiated. There was no palpable mass or axillary adenopathy on breast examination. She had multiple mammograms in the past, some of which had shown suspicious architecture, which was followed up with multiple breast ultrasounds that had revealed benign findings. Mammogram was repeated and was reported benign with BI-RADS 2. Nuclear bone scan was unremarkable. CT chest revealed no pulmonary lesions but there were small mediastinal, submental, and axillary lymphadenopathy and several subcutaneous lesions on the back (one of which was excised and showed inclusion epidermal cyst). Multiple myeloma workup was negative.\nWhile the workup was ongoing, the patient started to experience lower back pain associated with weakness of lower extremities, numbness, tingling, and balance issues. She developed constipation as well as urinary incontinence. MRI of the brain and spine redemonstrated similar bony lesions in vertebrae, and also revealed abnormal leptomeningeal enhancement in the brainstem extending along the entire spinal cord (Figure ). Due to this finding, the patient was admitted to the hospital for further workup. Her mentation was normal. Deep tendon reflexes were absent in lower extremities, Babinski was positive bilaterally, and gait was ataxic. Strength was overall 5/5 in upper extremities and 4/5 in lower extremities. Sensations to touch, pain, temperature, and vibration were normal. Cranial nerve examination was normal, and cerebellar signs were absent. Her thyroid-stimulating hormone was normal. Lumbar puncture showed increased protein (1187 mg/dL) and white blood cells 43 cells/uL (lymphocytes 70%, monocytes 30%) in CSF. CSF cytology was negative for carcinoma and showed numerous lymphocytes but the negative finding could also have been due to delay in processing the specimen. Peripheral blood flow cytometry revealed monoclonal B cell lymphocytosis, non-CLL type. Infectious workups including human immunodeficiency virus, rapid plasmin reagent, Epstein-Barr virus, herpes simplex virus, cytomegalovirus, lyme, and cryptococcal antigen were negative.\nFinally, right iliac bone biopsy was done that revealed metastatic adenocarcinoma, GCDFP-15 and GATA-3 positive, indicative of breast carcinoma. Estrogen (ER) positive (90%), progesterone (PR) positive (40%), human epidermal growth factor receptor 2 (HER-2)/neu non-amplified IHC 1+, and Ki-67 10%. Tumor markers CA 15-3, CA 27.29, and carcinoembryonic antigen were raised at 85 U/mL, 84.2 U/mL, and 7.1 ng/mL, respectively. She was started with letrozole initially with dexamethasone taper, followed by palliative radiation therapy. The radiation was given to lumbosacral spine with 30 Gy in 10 fractions, which improved her lower back pain. After completion of the radiation therapy, abemaciclib was added to letrozole as the systemic therapy. She showed excellent response to the treatment and her previously seen leptomeningeal enhancements are no longer seen in the follow-up scans (Figure ). She does continue to have sclerotic changes in her bones; however, she deferred from bone-targeted therapy. The patient has been on abemaciclib and letrozole for about two years, her neurological symptoms have improved, and now she has a good quality of life. She is able to walk half a mile on flat ground and is able to perform light household chores.
[[59.0, 'year']]
F
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{}
28
8675595-1
34,956,766
comm/PMC008xxxxxx/PMC8675595.xml
Rare Case of Central Pontine Myelinolysis: Etiological Dilemma
A 33-year-old female with no prior medical comorbidities, who recently gave birth to a healthy girl child four months ago, was brought to the emergency department with sudden onset weakness of both upper and lower limbs that started four days prior and rapidly progressed to a state of quadriplegia. She was conscious and obeyed simple commands with eyes and mouth; however, she had severe dysarthria. She had bilateral facial palsy and bulbar palsy. She had flaccid, hyporeflexic, pure motor quadriplegia with limbs showing only a subtle withdrawal flicker to pain. MRI of the brain revealed hyperintensity in the central pons in diffusion-weighted images (Figure ), T2-weighted images (Figure ), and fluid-attenuated inversion recovery (FLAIR) images (Figure ) without abnormal contrast enhancement (Figure ), consistent with central pontine myelinolysis (CPM) (Figure ).\nThe biochemical analysis showed hypernatremia while the remaining electrolytes were normal. The rest of the blood workup was unremarkable. Relatives denied an antecedent history of hyponatremia with rapid correction. The patient was started on sodium correction and was given five days intravenous (IV) pulse methylprednisolone 1 g/day to stabilize the blood-brain barrier. The patient recovered significantly to normal power. She was then considered to have idiopathic hypernatremic osmotic demyelination and was discharged with a modified Rankin Scale score (mRS) of 0.\nOne year later, she presented to the neurology department with a one-week history of generalized fatigue, diffuse myalgias, and three days history of rapidly progressive weakness of all four limbs making her wheelchair-bound one day before the presentation. Her initial vital signs were unremarkable. She was noted to have a pure motor flaccid symmetric quadriparesis with proximal more than distal weakness and generalized hyporeflexia. Clinical examination of other systems was normal. Nerve conduction studies (NCS) done on day three of onset of weakness demonstrated reduced compound muscle action potential (CMAP) amplitudes of bilateral tibial and peroneal nerves with absent F waves and H reflexes. CMAP of tested nerves in upper limbs showed preserved amplitudes with normal distal latency and absent F waves. There were no conduction blocks. The sensory conduction study of all the tested nerves in all four limbs was normal. Cerebrospinal fluid (CSF) analysis did not show albumin-cytological dissociation. Therefore, acute motor axonal neuropathy (AMAN) variant of Guillain-Barré syndrome (GBS) or hypokalemia-related electrophysiological abnormalities were considered. A basic metabolic panel revealed severe hypokalemia (potassium 2.2 mEq/L). Arterial blood gas (ABG) and 24-hour urine analysis showed metabolic acidosis, consistent with renal tubular acidosis type-1 (distal). Autoimmune workup was positive anti-SSA/Ro autoantibodies. The biopsy of the minor salivary gland was pathognomonic. The patient was diagnosed with pSS according to the new classification criteria proposed by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR). Overall clinical, electrical, and biochemical data suggest the presence of renal tubular acidosis with secondary hypokalemia-related quadriparesis due to pSS.\nThe patient was given intravenous (IV) potassium supplementation through a peripheral vein at a rate not exceeding 10 mEq/hour and subsequently was shifted to oral liquid formulation in the form of a syrup. Oral sodium bicarbonate supplementation was given at a dose of 1 mEq/kg/day for renal tubular acidosis. With potassium correction, there was a rapid recovery in the power of all four limbs within 24 hours of admission. The patient was initiated on 1 mg/kg/day of oral prednisolone and was referred to a rheumatologist for further management. She remained asymptomatic on her six-month follow-up.
[[33.0, 'year']]
F
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{'5413247-1': 1, '6534842-1': 1}
29
8675596-1
34,956,797
comm/PMC008xxxxxx/PMC8675596.xml
COVID Booster Shots: The Need of the Hour
A 67-year-old female with a past medical history of chronic obstructive pulmonary disease and history of long-term tobacco abuse, who recently quit smoking, presented with shortness of breath, cough, myalgias, and malaise for one week. The patient had received two doses of Pfizer COVID vaccine, with the second dose in February 2021. In the ER, her vital signs were blood pressure (BP) 120/71, heart rate (HR) 78 bpm, respiratory rate (RR) 20 breaths/min, oxygen saturation 85% on room air, and afebrile. Laboratory assessment on admission is in Table . Nasopharyngeal swab for SARS-CoV-2 was positive. Chest X-ray on admission shows mildly patchy bibasilar pulmonary infiltrates and a calcified pulmonary nodule in the mid-right lung (2.0 cm) (Figure ). The patient was admitted to the general medical ward and started on 6 L per minute of supplemental oxygen via nasal cannula, remdesivir, dexamethasone, furosemide, azithromycin, and enoxaparin for venous thromboembolism prophylaxis. Despite multiple measures, the patient did not improve, requiring more aggressive management. Repeat chest X-ray showed slight interval improvement of bilateral pulmonary infiltrates and needed 4-5 L per minute via nasal cannula (Figure ).
[[67.0, 'year']]
F
{'34525277': 1, '34529645': 1, '34619098': 1, '34437519': 1, '34706170': 1, '34956797': 2}
{'8675596-2': 2, '8675596-3': 2, '8675596-4': 2}
30
8675596-2
34,956,797
comm/PMC008xxxxxx/PMC8675596.xml
COVID Booster Shots: The Need of the Hour
A 58-year-old female with no significant past medical history presented with shortness of breath, fever, and cough for three days. The patient received two doses of the COVID vaccine, with the second dose in May 2021. In the ER, her vital signs were BP 105/96, HR 131 bpm, RR 20 breaths/min, oxygen saturation of 96% on room air, and febrile with a temperature of 102.0°F. Laboratory assessment is in Table . Nasopharyngeal swab for SARS-CoV-2 was positive. CT chest on admission shows no acute infiltrate and nonspecific nodules (Figure ). The patient was admitted to the general medical ward and started on antibiotics, dexamethasone, and remdesivir. The patient developed worsening hypoxia on Day 2, and CT chest showed widespread airspace disease throughout the lungs (Figure ). The patient required 4-5 L per minute via nasal cannula.
[[58.0, 'year']]
F
{'34525277': 1, '34529645': 1, '34619098': 1, '34437519': 1, '34706170': 1, '34956797': 2}
{'8675596-1': 2, '8675596-3': 2, '8675596-4': 2}
31
8675596-3
34,956,797
comm/PMC008xxxxxx/PMC8675596.xml
COVID Booster Shots: The Need of the Hour
An 84-year-old female with a past medical history of hypertension presented with weakness, dry cough, and shortness of breath for four days. The patient had received two doses of the COVID vaccine, with the second dose in March 2021. In the ER, her vital signs were BP 133/93, HR 103 bpm, RR 22 breaths/min, oxygen saturation of 96% on 40 L per minute of supplemental oxygen via high-flow nasal cannula, and afebrile. Laboratory assessment is in Table . Nasopharyngeal swab for SARS-CoV-2 RNA was positive. Chest X-ray on admission shows worsening right pleural effusion with new opacity obscuring the lower two-third of the right lung and a new pleural-based opacity in the left upper lobe (Figure ). CT chest with contrast shows large right pleural effusion and associated right basilar consolidation and abdominal ascites. The patient was admitted to the telemetry unit and started on methylprednisolone, piperacillin-tazobactam, remdesivir, and baricitinib. The patient clinically deteriorated on Day 2 and was transferred to the intensive care unit for thoracentesis and possible intubation. Thoracentesis removed 1.95 L of bloody, serosanguineous fluid obtained, with partial resolution of the effusion (Figure ). On Day 3, the patient developed septic shock, florid renal failure, and lethargy and was started on intravenous fluids and norepinephrine drip. Chest X-ray showed near-complete opacification of bilateral lung fields and subsequently was intubated. On Day 4, tense ascites were noted and the patient underwent paracentesis, which removed 4.25 L of bloody, serosanguinous fluid. Renal replacement therapy started. The patient was deemed to have a guarded prognosis with multiorgan failure.
[[84.0, 'year']]
F
{'34525277': 1, '34529645': 1, '34619098': 1, '34437519': 1, '34706170': 1, '34956797': 2}
{'8675596-1': 2, '8675596-2': 2, '8675596-4': 2}
32
8675596-4
34,956,797
comm/PMC008xxxxxx/PMC8675596.xml
COVID Booster Shots: The Need of the Hour
A 48-year-old male with a past medical history of type 2 diabetes mellitus and end-stage renal disease on hemodialysis presented with shortness of breath for three days. The patient was transferred from an outside facility where he was found to be hypoxic, saturating 79% on room air, chest X-ray showing infiltrates, and a positive nasopharyngeal swab for SARS-CoV-2 RNA. The patient had received two doses of the COVID vaccine, with the second dose in March 2021. Upon arrival to the general medical ward, the patient's vital signs were BP 132/79, HR 84 bpm, RR 18 breaths/min, oxygen saturation of 100% on 2-4 L per minute of supplemental oxygen via nasal cannula, and afebrile. Laboratory assessment is in Table . The patient was quickly weaned to room air, with SpO2 of 94-98%; hence, only supportive care was provided for COVID-19. On Day 1, the patient was found to have a right foot wound infection and was started on intravenous vancomycin and piperacillin-tazobactam. On Day 2, the patient was found to be hypoxic, put on 5 L per minute of supplemental oxygen via nasal cannula, and started on dexamethasone and remdesivir. Because of end-stage renal disease, the patient did not qualify for baricitinib. On Day 4, the patient required 10 L per minute of supplemental oxygen via high-flow nasal cannula, which he needed until Day 12, when we could start weaning down the supplemental oxygen over the next 3-4 days until Day 15 to room air. On Day 17, the patient was put back on 2 L per minute of supplemental oxygen via a nasal cannula which quickly escalated to 15 L on a nonrebreather mask within 2-3 hours, requiring the patient to get transferred to the intensive care unit on Day 18. At this time, he was put on bilevel positive airway pressure (BiPAP) with 40 L per minute of supplemental oxygen. Chest X-ray showed extensive diffuse airspace infiltrates, which significantly worsened from one week prior (Figure ). He was dialyzed without improvement from a respiratory standpoint and then intubated on Day 19. Subsequently, the patient was restarted on dexamethasone and broad-spectrum antibiotics despite completing 14 days' worth previously.
[[48.0, 'year']]
M
{'34525277': 1, '34529645': 1, '34619098': 1, '34437519': 1, '34706170': 1, '34956797': 2}
{'8675596-1': 2, '8675596-2': 2, '8675596-3': 2}
33
8675599-1
34,956,759
comm/PMC008xxxxxx/PMC8675599.xml
Myocarditis Post Moderna Vaccination: Review of Criteria for Diagnosis
A 23-year-old Caucasian male with a history of exercise-induced asthma presented to the emergency department complaining of left-sided chest pain which started two days after receiving the second dose of the mRNA-1273 Moderna vaccine. The patient described the pain as sharp, intermittent with radiation to the left upper back and left arm with 10/10 severity and worsening with deep inspiration. Fever and chills were also present. The patient did not report any recent history of tick bites, upper respiratory symptoms, paroxysmal nocturnal dyspnea (PND), orthopnea, arthralgias or rashes.\nOn physical examination the patient was in no distress, with normal vital signs, normal S1/S2 heart sounds without any murmurs, rubs, or gallops and no jugular vein distention (JVD). There was no palpable tenderness of the chest wall. The lungs were clear to auscultation. There was no pitting edema in the lower extremities.\nDiagnostic testing revealed elevated troponin T of 475ng/L (<22ng/L) which trended upward reaching a peak of 910ng/L (<22ng/L). Initial electrocardiogram (ECG) showed right axis deviation with left posterior fascicular block without any ST elevations as well as premature atrial contractions (PACs) in trigeminy (Figure ). A bedside ultrasound showed trace pericardial effusion. CT angiography (CTA) of the chest was negative for pulmonary embolism (PE). Lyme serology, antinuclear antibodies (ANA) and respiratory viral panel were negative and thyroid stimulating hormone (TSH) was normal. Pertinent leukocytosis of 11.09 K/ul (3.8-10.5 K/Ul) with absolute neutrophil count of 8.09 K/uL, elevated erythrocyte sedimentation rate (ESR) of 37mm/hr (0-15mm/hr), c-reactive protein (CRP) of 11.6mg/L (<4.0mg/L). Urine toxicology was positive for recreational marijuana drug use but negative for cocaine use.\nTransthoracic echo (TTE) revealed abnormal motion and increased thickening of the septal wall with preserved ejection fraction (EF) of 65% and normal diastolic function (Video ). Trace pericardial effusion was also noted. Based on the patient’s clinical presentation, ECG, cardiac markers and TTE findings a presumptive diagnosis of peri-myocarditis was made.\nWe did not pursue cardiac MRI since the patient had clinically improved within 48 hrs. He received aspirin 325 mg once followed by indomethacin 50mg twice a day and discharged on day three to complete a total of two weeks indomethacin and three months of colchicine 0.6mg daily. Complete resolution of his symptoms, normalization of troponins and ECG, was demonstrated within two weeks during follow up. At his 60-day follow-up visit, TTE confirmed resolution of the wall motion abnormality and pericardial effusion and he remains completely symptom free at 128 days.
[[23.0, 'year']]
M
{'23824828': 1, '34347001': 1, '34185046': 1, '34277198': 2, '34447639': 2, '31902242': 1, '34407340': 1, '17959655': 1, '34614328': 1, '34660088': 2, '34185045': 1, '34614329': 1, '29032361': 1, '34956759': 2}
{'8504680-1': 1, '8381757-1': 1, '8270057-1': 1, '8270057-2': 1}
34
8675801-1
34,956,757
comm/PMC008xxxxxx/PMC8675801.xml
Sequelae of a Rare Case of Penetrating Parotid Gland Injury: Ultrasound and Magnetic Resonance Imaging Features
A 35-year-old male presented with a foreign body in his left ear caused by a trauma to the left parietal area by a fishhook. The patient was in a boat on a fishing trip when the fishhook accidentally pierced his upper neck behind the left auricle and pierced the auricle of the left ear. On examination, the patient was conscious and oriented and no bleeding, swelling, hematoma or bruises were noticed. Vital measurements and systemic review revealed normal findings. The patient received an intramuscular injection of 0.5 mL tetanus toxoid adsorbed vaccine and was referred for surgical assessment and foreign body removal. Under local anesthesia, the triple needle fishhook was removed and cut by a bone nipper from left pinna and post-auricular area (Figure ). The lacerated wound was stitched by 05 Ethilon suture, left mastoid dressing was applied and the patient was discharged after prescribing per-oral cefuroxime and diclofenac for five days.\nTwo weeks later, the patient returned to the hospital for follow-up. On examination, left pinna and post-auricular area were normal. However, a small, non-tender, firm 2 x 2 mm subcutaneous swelling was noticed below the ear lobule. Amoxicillin/clavulanate and diclofenac sodium were prescribed, and the patient was discharged.\nIn the follow-up visit two months after the injury, the patient was assessed for a localized small, non-tender, 2 x 2 mm parotid swelling at the angle of mandible on the left side. The swelling appeared after the removal of the foreign body two months ago and did not get resolved. Ultrasound (US) of the neck showed a linear hypoechoic focus in the superficial parotid gland extending to the subcutaneous tissue (Figure ). The presence of scar or granulation tissue was suspected and no focal mass lesions were detected. In addition, a few oval-shaped, non-specific cervical lymph nodes were noted with preserved fatty hilum and a short axis diameter of 0.8 cm. Magnetic resonance imaging (MRI) confirmed the presence of a post-traumatic scar and granulation tissue involving the superficial part of the left parotid gland and extending to the subcutaneous soft tissue (Figure ). The presence of bilateral non-specific lymph nodes was noted in both cervical regions.
[[35.0, 'year']]
M
{'3967129': 1, '19764678': 1, '7861286': 1, '2910210': 1, '19348990': 1, '2231807': 1, '1806507': 1, '34956757': 2}
{}
35
8676056-1
34,956,762
comm/PMC008xxxxxx/PMC8676056.xml
Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis (SAPHO): A Case Report
An 18-year-old male patient presented to the emergency department with right hip pain for two weeks. Examination revealed pain and mild to moderate tenderness in the right hip joint. The range of motion was decreased, and trying to initiate movement caused severe pain to the extent that the patient could not walk for gait assessment. Past history revealed similar but less severe episodes for the last four years. There was no history of fever, skin rash, or acne. His inflammatory laboratory investigations, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), were within the normal limits. X-rays of the pelvis and right thigh were unremarkable except for a small lucency in the right greater trochanteric region (Figure ).\nSubsequently, an MRI of the right thigh showed trochanteric bursa effusion and right hip joint synovitis (Figures , ).\nNon-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol were started for the management, and the patient showed excellent improvement for the first three months.\nHe remained well for four months, after which he developed swelling of the right sternoclavicular joint. X-ray of the joint and laboratory investigations were found to be normal (Figure ).\nDue to the previous history of the right hip joint, the lesion was investigated further with MRI (Figures , , ).\nA patchy area of hyperintensity on T2 and hypointensity on T1 images close to the sternoclavicular junction was observed. On post-contrast images, there was a mild accentuated heterogeneous enhancement. Traces of fluid was also noted in the joint space, and marrow edema was seen along the articular margin and body of the sternum. MRI also showed subcutaneous edema and changes related to cellulitis in the overlying soft tissues. Clinical history and imaging data were suggestive of SAPHO syndrome. The patient was again started on paracetamol and NSAIDs based on the excellent previous response. At the one-month follow-up, the swelling was found to have improved. The patient was continued on the therapy and his symptoms resolved within three months.
[[18.0, 'year']]
M
{'10966214': 1, '18721907': 1, '24620738': 1, '10622680': 1, '24182852': 1, '18559374': 1, '16989598': 1, '17347017': 1, '9601969': 1, '23153960': 1, '29924019': 2, '25009594': 2, '34956762': 2}
{'8676056-2': 2, '4079404-1': 1, '6024477-1': 1}
36
8676056-2
34,956,762
comm/PMC008xxxxxx/PMC8676056.xml
Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis (SAPHO): A Case Report
A 35-year-old male patient presented with a six-month history of pain in the anterior chest and neck. His pain initially had been mild but had become severe in the last three weeks. He was afebrile and did not have any constitutional symptoms. On examination, marked tenderness of the right sternoclavicular joint was noted. Initial laboratory investigations, tuberculosis workup, and chest X-rays were unremarkable. However, further study with MRI revealed subchondral bone marrow edema and enhancement involving the medial end of the right clavicle. In addition, mild effusion of the right sternoclavicular joint and surrounding soft-tissue edema was also seen (Figure , ).\nGiven the patient's radiological and clinical findings, suspicion of SAPHO syndrome was raised. He was given an initial trial of paracetamol and NSAIDs and he showed remarkable improvement on his monthly follow-up visits. Though a biopsy was offered, the patient refused to undergo one and has shown no relapse to date thanks to the dramatic response to NSAIDs.
[[35.0, 'year']]
M
{'10966214': 1, '18721907': 1, '24620738': 1, '10622680': 1, '24182852': 1, '18559374': 1, '16989598': 1, '17347017': 1, '9601969': 1, '23153960': 1, '29924019': 2, '25009594': 2, '34956762': 2}
{'8676056-1': 2, '4079404-1': 1, '6024477-1': 1}
37
8677335-1
34,956,764
comm/PMC008xxxxxx/PMC8677335.xml
Acute Pancreatitis as a Sequela of Hypertriglyceridemia Due to Hyperosmolar Hyperglycemic Syndrome
A previously healthy 49-year-old female with a past medical history of well-controlled hypertension and body mass index (BMI) of 30.37 kg/m2 presented to the emergency department with altered mental status, abdominal pain, hematemesis, and hypotension. According to family, the patient complained of abdominal pain earlier that morning and was later found at home minimally responsive and recurrently vomiting blood.\nIn the emergency department, the patient’s vitals included a blood pressure of 94/50 mmHg, a temperature of 87.1 Fahrenheit, and a respiratory rate of 34 breaths per minute. The patient was intubated for airway protection. She received 5L of fluid as well as one unit of packed red blood cells for suspected large fluid volume loss. Esophagogastroduodenoscopy was performed and was remarkable for a Mallory-Weiss tear with portohypertensive gastropathy. This was thought to be caused by the repeated vomiting reported by her family. CT scan showed peripancreatic edema and fat stranding, consistent with acute pancreatitis (Figure ). A repeat CT scan was done to evaluate the progression of her pancreatitis, which showed worsening pancreatitis with developing ascites. Labs were remarkable for a glucose up to 955 mg/dL, hemoglobin A1c (HgbA1c) of 13.7%, and a triglyceride level up to 1608 mg/dL (Table ). The patient was then placed on an insulin drip for her significantly elevated blood glucose. After her glucose normalized, she was continued on an insulin drip until her triglycerides dropped below 500 mg/dL. The patient was then downgraded to the general medical floor and discharged after being able to tolerate a regular diet without significant pain or discomfort.
[[49.0, 'year']]
F
{'30939294': 1, '25342831': 1, '34956764': 2}
{}
38
8690961-1
34,930,443
comm/PMC008xxxxxx/PMC8690961.xml
Feminizing adrenocortical adenoma in a girl from a resource-limited setting: a case report
A 53-month-old Sudanese female presented with progressive bilateral breast enlargement and accelerated growth since the age of 9 months. Her family had sought medical advice several times in different primary health care facilities and were reassured. She had no vaginal bleeding and no pubic or axillary hair.\nExamination showed a well-looking girl, vitally stable with normal blood pressure. Her weight was 17 kg (50th centile) and height 108 cm (90th centile) using the Centers for Disease Control and Prevention growth chart. Mid-parental height was 175 cm and predicted adult height was 167 cm using the JM Tanner formula. No previous documented follow-up growth data were available. Her Tanner staging was A1, P1, and B3. She had reddish mucoid vagina. She had no clitoromegaly, acne, hirsutism, or palpable abdominal mass (Table ).\nLeft wrist X-ray revealed a bone age of 8 years.\nThe hormonal evaluation using fluorometric enzyme immunoassay showed basal luteinizing hormone of 3.1 mIU/L, which increased to 8.8 mIU/L 45 minutes post-gonadotrophin-releasing hormone stimulation. Elevated levels of estradiol E2 29,000 pg/ml (5–15 pg/ml), and dehydroepiandrosterone sulfate 90 ng/mL (2.3 ng/mL), with normal early morning cortisol level 16 ng/mL (7–28 ng/mL). Due to financial difficulties, we did not measured the follicular-stimulating hormone level.\nAbdominal ultrasound revealed a right-sided hypoechoic suprarenal mass, an ovarian volume of 1.8 cm3, uterine volume of 3 cm3, and endometrial thickness of 1.2 cm. The abdominal CT scan showed a 25 × 22 mm well-defined rounded focal lesion with a smooth outline, at the level of the right adrenal gland with homogeneous attenuation, HU-7 on a noncontrast scan, and no evidence of local tissue invasion (Fig. ). The left adrenal gland and ovaries were normal.\nBrain magnetic resonance imaging was done to exclude a central cause of precocious puberty and was normal. Complete hemogram, liver, and renal functions were normal.\nA diagnosis of an estrogen-secreting right adrenocortical tumor was made, and we referred the patient to surgery.\nDuring laparotomy a 3 cm diameter tumor in the right adrenal gland was completely excised. The histopathological examination showed well-circumscribed tumor forming nests with trabeculae and sheets of polygonal cells with eosinophilic cytoplasm. The tumor was not infiltrating the capsule, with no mitosis, atypia, or necrosis (Wieneke index score = 0). Findings suggestive of benign adrenal cortical adenoma.\nThe postoperative evaluation revealed normal cortisol and dehydroepiandrosterone sulfate. Estradiol E2 40 pg/mL was consistent with secondary central precocious puberty, so the patient was started on monthly gonadotrophin-releasing hormone agonist, with a regular follow-up plan for the possibility of recurrence of adrenal adenoma.\nSix months after the operation, the patient was well and compliant to monthly gonadotrophin agonist injections. She showed partial regression of her secondary sexual characters and a growth velocity of 5 cm/year. The abdominal CT scan was normal with no evidence of recurrence.
[[53.0, 'month']]
F
{'29239032': 1, '11283875': 1, '25932386': 1, '17021581': 1, '30684056': 1, '21932594': 1, '28476230': 1, '34930443': 2}
{}
39
8691080-1
34,930,266
comm/PMC008xxxxxx/PMC8691080.xml
Secondary myelodysplastic syndromes identified via next-generation sequencing in a non-small cell lung cancer patient
A 66-year-old male with back pain and cough for two weeks was admitted to the First Hospital of Jiaxing on 8 August 2019. A thoracic computed tomography (CT) scan revealed that the malignant tumor on the left upper lobe was complicated by distal obstructive inflammation, the enlargement of the left hilar and mediastinal lymph nodes, and the multiple bone metastases on 25 August 2019 (Fig. A). Immunohistochemical (IHC) results of the posterior iliac bone marrow biopsy specimen showed the positive expression of CD3, CD20, CD34, CD235a, and NPO, and the negative CD61 expression. IHC results of an endoscopic biopsy specimen of the bronchial mucosa on the upper left lobe showed the positive expression of TTF1, CK7, NapsinA, Ki67, CK, and EMA, and the negative expression of CK5/6, P40, CgA, Syn, and CD45 on 6 September 2019. Histopathologic observations showed infiltration of atypia cells in mucosal and fibrous tissues. The detection tools of pathology and cytology included automatic IHC staining (BenchMark XT, Roche, The United States), digital slice scanner, image analysis software (Pannoramic 250, 3DHistech, Hungary), and microscope (Eclipse Ci-S, Nikon, Japan). Finally, the patient was diagnosed with stage IVb lung adenocarcinoma combing with bone metastases.\nTo seek potential therapeutic opportunities, the FFPE tissue and control sample (white blood cell) of the patient were detected using a 733-gene NGS panel in a College of American Pathologists (CAP) and Clinical Laboratory Improvement Amendments (CLIA) certificated lab. Sequencing reads were mapped against the hg19/GRCh37 genome, and duplicate reads were removed, followed by variants calling in targeted regions using an in-house developed bioinformatics algorithm. The algorithm utilized a filtering model containing background error correction, strand bias, base quality, mapping quality, short tandem repeat regions, and low-quality mapping ratio 25 []. The NGS analysis results indicated that the patient had an EGFR exon 19 p.L747_S752del somatic mutation with an allelic fraction of 73.19% and TP53 p.H179L germline mutation. Besides, the whole chromosome 7 and 5q deletion were detected using NGS-based copy number variation (CNV) analyses (Fig. ), which were classical abnormalities associated with MDS. According to the clinical inquiry, the patient was a farmer by occupation, which means that he has long been exposed to certain chemicals such as pesticides, fertilizers, and solvents containing benzene. In addition, he smoked for 40 years. Taking all these findings together, we suspected the patient with secondary MDS. The results of the physiological blood indexes and the bone marrow aspiration test showed a decrease of platelet counts and the elevation of myelocyte counts. The proportion of blast was 5%, and the morphology of the cells presented the characteristics of MDS, which further confirmed our speculation (Fig. and Additional file : Fig. S1).\nIn terms of treatment, the EGFR-positive mutation patient was administered with gefitinib starting from 20 August 2019. Due to decreasing platelet counts, azacitidine was administrated for four courses of treatment. However, the thrombocytopenia had not been significantly improved, and the size of the maximal tumor in the lung lesion did not decrease after seven months’ treatment (Fig. B). On 10 April 2020, a pathological report showed the infiltration of poorly differentiated cancer cells into the fibrous tissue. IHC results suggested the neuroendocrine tumor, in which small cell carcinoma and atypical carcinoid tumor accounted for about 40% and 60%, respectively. On 7 April and 28 April 2020, considering positive PD-L1 expression and high tumor mutation burden (TMB) in the tissue sample, the patient was administrated with toripalimab (a PD-1 inhibitor) and bevacizumab. Platelet counts returned to near-normal levels gradually, and the tumor lesion shrank obviously (Fig. ). It was concluded that the patient reached a partial response (PR) (Fig. C). The progression-free survival was four months.
[[66.0, 'year']]
M
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{}
40
8692721-1
34,956,806
comm/PMC008xxxxxx/PMC8692721.xml
Isolated Chest Wall Necrotizing Fasciitis: An Unusual Fatal Manifestation of Extrapulmonary Tuberculosis
A 22-year-old male presented in the emergency department with acute onset of swelling and redness over the right side of the neck and chest wall for the last three days. He had features of septicemia such as drowsiness or Glasgow Coma Scale score of 11/15, respiratory rate of 26 breaths per minute, pulse rate of 130 beats per minute, blood pressure of 84/56 mmHg, and urine output of 15 mL/hour. He had no history of chronic disease, drug reaction, trauma, unknown bite, or significant familial disease. Blood investigations revealed low hemoglobin of 7.6 g/dL, raise leukocyte count of 28000/mm3, low albumin of 2.2 g/dL, raised serum creatinine of 2.23 mg/dL, serum urea of 174 mg/dL, and low sodium of 125 mEq/L. Serological markers including erythrocyte sedimentation rate (95 mm/hour) and procalcitonin (25.2 ng/mL) were higher. X-ray of the chest was grossly normal (Figure ), and contrast-enhanced computed tomography (CECT) of the neck revealed irregular, well-defined, hypodense, non-enhancing area in the right parotid gland with extension into the neck spaces, larynx, and subcutaneous planes (Figure ). CECT of the chest revealed mild effusion in bilateral pleural space secondary to acute infection and no evidence of lymphadenopathy or osteomyelitis (Figures , ).\nZiehl-Neelsen (ZN) staining from pleural fluid was negative for acid-fast bacillus (AFB bacilli). The patient was managed in the intensive care unit with ventilator support due to acute respiratory distress syndrome. He was diagnosed with acute progressive necrotizing fasciitis with multiple organ dysfunction syndromes due to an unknown cause of septicemia. He underwent multiple aggressive debridements of the neck and chest wall (Figure ).\nThe cartridge-based nucleic acid amplification test (CBNAAT) and ZN staining revealed positive mycobacteria and AFB bacilli for pathological tissue. Therefore, the pus collected in the parotid region and neck space was likely secondary to tubercular infection. A split-thickness graft was applied in multiple fractions after three weeks of anti-tubercular chemotherapy. The patient had a long hospital stay due to the difficult location and complexity of the ulcer over the neck. He was followed up for six months in good clinical condition after discharge.
[[22.0, 'year']]
M
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{'6055216-1': 1, '6708553-1': 1}
41
8693491-1
34,933,668
comm/PMC008xxxxxx/PMC8693491.xml
Bilateral stress fracture of the femoral neck in association with simultaneously developing osteonecrosis of the femoral head: a case report
A 41-year-old Japanese woman presented to our clinic with a 4 month history of bilateral groin pain and right buttock pain. Her right hip was more painful than her left hip. There was no history of trauma, alcohol abuse, or steroid use. Her medical history included iron-deficiency anemia diagnosed 2 years earlier, after which she had been on iron supplements. She had no fracture episodes, including fragility fractures.\nHer height, body weight, and body mass index were 155 cm, 42 kg, and 18.7 kg/m2, respectively. She was able to walk for approximately 10 minutes without a stick, albeit at a slow speed. Limitations in the passive motion of her bilateral hip joint were observed thus: flexion, 100°, internal rotation 5°, external rotation 15°, and abduction 20°, on both sides. She was able to perform a straight-leg raise of the right limb with substantial pain. The neurovascular status of both lower extremities was intact. The Japanese Orthopaedic Association scoring system for the evaluation of hip-joint function (JOA hip score) was 46 points for her right hip and 56 points for her left hip. The score was based on a total of 100 points, comprising 40 for pain, 20 for range of motion, 20 for the ability to walk, and 20 for activities of daily living [].\nStandard radiographs of both hips (Fig. a–c) demonstrated no characteristic findings such as the crescent sign, sclerotic band pattern, and collapse of the femoral head, and no joint space narrowing was seen in either femoral head. MRI of both hips (Fig. d, e) presented a low signal line in the subchondral region of the femoral head in the T1 weighted image and high signal region in almost all of the femoral head in the short tau inversion recovery (STIR). The oblique axial views of the proton density-weighted image showed a low-signal sinuous line in the anteromedial region of the femoral head (Fig. ). Dual-energy X-ray absorptiometry (DEXA) values were low in both femoral necks. Bone mineral density was 0.909 g/cm2 (T-score –0.9, Z-score −0.8) in the lumbar spine, 0.594 g/cm2 (T-score −1.8, Z-score −1.4) in the right femoral neck, and 0.529 g/cm2 (T-score −2.4, Z-score −2.0) in the left femoral neck. Laboratory findings were as follows: C-reactive protein (CRP) 0.03 mg/dl (normal range: 0–0.5 mg/dl); alkaline phosphatase 608 IU/l (40–150 IU/l); calcium 9.0 mg/dl (8.4–10.2 mg/dl); albumin 4.4 g/d (3.9–4.9 g/d); and hemoglobin 9.7 g/dl (12–16 g/dl). Bone turnover markers were as follows: tartrate-resistant acid phosphatase 5b (TRACP-5b) 463 mU/dl (premenopausal normal range: 120–420 mU/dl) and total procollagen type 1 N-terminal propeptide (Total P1NP) 72.7 ng/ml (26.4–98.2 ng/ml). We diagnosed bilateral osteonecrosis of the femoral head and classified it as stage 1 in both femoral heads, according to the Association Research Circulation Osseous (ARCO) classification [].\nThe patient was instructed not to take as much weight as possible using sticks on the right side. Her symptoms improved immediately. However, 6 months later, her symptoms increased slightly without any traumatic episodes. Radiographic findings indicated almost no change (Fig. a–c). However, a slight signal change in the medial subcapital region was observed in the MRI scan (Fig. d, e). Her pain gradually increased thereafter, and 10 months after her first visit, walking became difficult. The JOA hip score decreased to 34 points in both hips; still, no changes could be observed in the radiograph (Fig. a–c). MRI of both hips showed a nondisplaced subcapital fracture on the medial side of both femoral necks, with bone marrow edema around the fracture (Fig. d, e). Because the cause of the fractures was not identified, the DEXA and bone turnover markers were measured again, and 25-hydroxy (OH) vitamin D was measured for the first time. All DEXA values decreased. The bone mineral density was 0.849 g/cm2 (T-score −1.5, Z-score −1.2) in the lumbar spine, 0.527 g/ cm2 (T-score −2.4, Z-score −2.1) in the right femoral neck, and 0.490 g/cm2 (T-score −2.7, Z-score −2.4) in the left femoral neck. TRACP-5b level increased to 607 mU/dl, and total P1NP decreased to 52.7 ng/ml. Her 25(OH) vitamin D level was 11.1 ng/dL and she was diagnosed with vitamin D deficiency. Based on the above results, our diagnosis was bilateral stress fracture of the femoral neck secondary to osteonecrosis of the femoral head. The patient underwent internal fixation of both hips with sliding hip screws (Dual SC screw system; Kisco, Kobe, Japan) to stabilize the stress fractures. In addition, the reaming performed before inserting of the sliding hip screw served as core decompression for the femoral heads [, ]. The specimens obtained from the reaming were examined histologically. Definitive findings of osteonecrosis such as bone marrow necrosis and loss of osteocyte nuclei in the femoral heads were observed (Fig. ). Postoperative radiographs showed no evidence of displacement of the fractures (Fig. ). We administered eldecalcitol 0.75 μg per day orally for vitamin D deficiency, and daily subcutaneous injections of teriparatide acetate. In the immediate postoperative period, the patient began to bear weight as tolerated with the use of an assistive device bilaterally. One month postoperatively, she was able to walk without pain and used a cane part time. She eventually regained full walking ability without a cane 3 months after surgery. Furthermore, her JOA hip score improved to 90 points in both hip joints at 5 months after surgery. Radiographs showed no evidence of recurrent stress fracture in the femoral neck or progression of osteonecrosis (Fig. ). Sequential oblique axial MRI showed that the necrotic region of the femoral head had decreased 5 months after surgery (Fig. ).
[[41.0, 'year']]
F
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{}
42
8693492-1
34,937,572
comm/PMC008xxxxxx/PMC8693492.xml
Coexistence of antithrombin deficiency and suspected inferior vena cava atresia in an adolescent and his mother – case report and clinical implications
A 14-year-old male adolescent presented to the emergency department with subfebrile temperatures for 1 week and localized pain in his right popliteal fossa for 3 days. Prior to the onset of these symptoms, he had been immobilized for several days following a minor sports injury.\nThe adolescent had no permanent medication and no prior medical history except for an asymptomatic ATD diagnosed at the age of six by functional antithrombin assay (antithrombin activity of 57%, age adapted reference: 77–125%). Since at that time, there were no clinical signs of thrombosis, the diagnosis of ATD did not lead to any therapeutic consequences. Screening for ATD at this early age had been carried out on parental request, as his mother was diagnosed with ATD in her early adulthood. Interestingly, his mother now reported that she had very recently been diagnosed with IVCA (preexisting chromogenic test results showed an antithrombin activity of 50% for the mother, the age adjusted reference range being 80 to 130%).\nThe coexistence of other hereditary thrombophilic disorders in our patient and his mother (protein S deficiency, protein C deficiency, factor V Leiden mutation, prothrombin-mutation, antiphospholipid syndrome) was ruled out by respective laboratory analyses.\nLaboratory blood analysis in the emergency department showed markedly elevated D-dimers of 25 mg/l FEU (reference: < 0.5 mg/l FEU) and of C-reactive protein (CrP) of 184 mg/l (reference < 5 mg/l). Antithrombin activity on admission was reduced to 61% (age adjusted reference 83–118%).\nA vascular ultrasound examination upon admission confirmed the clinically suspected thrombosis of the right lower extremity involving the external iliac, common and superficial femoral as well as the popliteal vein. The ultrasound examination of the left lower extremity veins did not give evidence of thromboses upon admission. The patient was treated with continuous infusion of unfractionated heparin at a therapeutical dose including several bolus administrations and antithrombin (4000 IE within the first 36 h) was substituted reaching levels in the target range between 80 and 100%. Subsequent monitoring of the activated partial thromboplastin time (aPTT) showed an insufficient response to heparin treatment (aPTT was 29 s before the administration of heparin and did not exceed a maximum value of 33.6 s during heparin treatment). The anticoagulative therapy was therefore switched to direct thrombin inhibition by argatroban at a dose of 1.5–2.0 μg/kg/min, which led to target aPTT values of 50–60s.\nDue to the elevated CrP levels and subfebrile temperatures, empirical antibiotic treatment with intravenous cefuroxim was initiated.\nA magnetic resonance imaging (MRI) scan on day three confirmed a complete DVT of the right lower extremity, and now additionally extended thromboses of the left lower extremity and thrombosis of both iliac vessels. Furthermore, it revealed an occlusion of the inferior vena cava (IVC) with prominent venous lumbar collaterals, suggestive of IVCA. Surrounding the lumbar vertebrae, several of these collaterals appeared to be fully thrombotic, which was confirmed by angiography (Fig. A).\nThe following day, a catheter-directed local thrombolysis using recombinant tissue plasminogen activator (rt-PA) at a daily dose of 0.25 mg/kg was initiated in both extremities and carried out for a total of 48 h. For the right leg, an additional ultrasound-accelerated thrombolysis using the EKOS® system was performed.\nDuring hospitalization, the anticoagulative therapy was switched from argatroban to the vitamin K antagonist phenprocoumon with a target International Normalized Ratio (INR) of 2.0–2.5. Oral anticoagulation will most likely be continued lifelong due to the combination of extended multilocal thromboses with underlying ATD, as well as IVCA, which in itself is a risk factor for thrombosis.\nThe patient was discharged on day eight after hospital admission. An ultrasound examination upon discharge showed full recanalization of the femoral and iliac veins of both legs.\nDuring a routine follow-up 1 week later, the patient presented free of any clinical complaints. However, despite continued oral anticoagulation since hospital discharge, vascular ultrasound now revealed extended re-thrombosis of both the right and left pelvic axis and the right lower extremity, thus leading to a second hospital admission and re-induction of therapy with both intravenous antithrombin and catheter-directed thrombolysis.\nRecanalization of the right lower extremity and pelvic axis was subsequently achieved, whereby IVC occlusion was confirmed (Fig. B). However, the left pelvic vessels remained thrombotic even after 5 days of catheter-directed thrombolysis.\nSurprisingly, one of the angiographies allowed for location of the occluded area of the IVC by rendezvous-technique between the superior and inferior vena cava, which prior to this had been thought to be atretic (Fig. C). The vessel was successfully recanalized using balloon dilation and subsequent stenting (Fig. D).\nThroughout the clinical stay, the patient’s oral anticoagulation with phenprocoumon was intensified to a new target INR of 2.5–3.0 in order to prevent re-thrombosis.\nThe patient was discharged from hospital on day seven after admission. Regular follow-up examinations at our outpatient clinic did not give evidence for any new thrombotic events to date (time since first occurrence of thrombosis was 9 months).\nConcerning the thrombotic left iliac vessels, a follow-up angiographic intervention relying on special equipment was performed, but recanalization could not be achieved.\nFortunately, the IVC of the patient’s mother could also be recanalized by angiographic intervention.
[[14.0, 'year']]
M
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{}
43
8693538-1
34,956,790
comm/PMC008xxxxxx/PMC8693538.xml
Management of an Unusual Central Nervous System Metastasis With Linear Accelerator Radiosurgery in a Low-Middle Income Country
The patient is a 68-year-old retired male, born in Aloag and resident of Tambillo (a rural locality in the vicinity of the capital of Ecuador, Quito). His medical history was significant only for being a heavy smoker until 2016 (with a calculated 20 pack-year), copious alcohol consumption every 15 days until 2010 and a myocardial infarction in 2015, successfully treated with stenting, acetylsalicylic acid and atorvastatin, a medication that he continues until this day. There is no family history of cancer or other pathologies of interest.\nIn February 2020, he presented dysesthesias in the right hemithorax associated with pain and a mass-like sensation in the same region. This prompted a visit to his local healthcare center (part of the public health network) where a chest CT scan was ordered in March 2020 revealing a solitary pulmonary mass located in the right inferior lobule with an invasion of both the pleura and thoracic wall. However, due to the beginning of the COVID-19 pandemic in Ecuador, all further studies were suspended for two to three months, resulting in a significant delay of the biopsy, which was undertaken on May 17, 2020. The histopathological study reported a neuroendocrine carcinoma. The patient was subjected to a thoracotomy and inferior pulmonary lobectomy on June 7, 2020 and was afterward treated with four cycles of chemotherapy consisting of cisplatin and etoposide until November of the same year. In December, the patient presents with neurologic symptoms consisting of loss of balance, ataxic gait, headaches, and nausea, prompting the necessity of a brain MRI. The study revealed a mass on the right lobe of the cerebellum (2.66 x 2.61 x 2.48cm) with perilesional edema, compressing the fourth ventricle. A progression of his primary lung cancer was diagnosed, the original chemotherapy regimen was suspended and replaced with adjuvant Temozolomide maintenance therapy, and he is referred to the radiotherapy service for WBRT with 20 Gy divided into five fractions, which improved his symptoms.\nHowever, in March 2021, the patient comes to our hospital’s radiotherapy department to request a second opinion due to the reappearance of his neurological symptoms (loss of balance, headaches, nausea, dizziness, and photophobia). The physical examination is relevant for a Glasgow Coma Scale of 15, oriented in time, place, and person, incapacitating ataxic gait (the patient needs to be mobilized in a wheelchair), and severe photophobia requiring the constant use of sunglasses. The rest of the neurological examination is normal including cranial nerves, reflexes, and somatosensory function. Relevant prognostic indexes were calculated and included the Karnofsky Performance Scale (KPS) of 80%, and the Graded Prognostic Assessment (GPA), specific for patients with brain metastasis, of 3. A CT scan of the thorax, abdomen and pelvis was obtained, on February 22, 2021, in order to detect any new tumoral or metastatic activity; however, none was found (Figures -). Therefore, a follow-up MRI was ordered on February 23, 2021, which revealed two intra-axial lesions on the right cerebellar hemisphere and near the right lateral ventricle, respectively (Figures -).\nDue to the aforementioned clinical and imaging findings, radio-surgical management of the disease with 21Gy, in one fraction, delivered with a linear particle accelerator (LINAC), TrueBeam® (Varian Medical Systems, Inc., Palo Alto, CA) was offered to the patient; immobilization was performed with a thermoplastic mask and Precise Bite mouthpiece (Solstice™ SRS Immobilization System, Orange City, IA); treatment simulation was done on the CT images and volume definition was performed in the contrasted T1 MRI with SPACE sequence; Gross tumor volume (GTV) was defined as the signal enhancing hyperintense tumoral regions observed on MRI and planning target volume (PTV) was prolonged 1mm in all directions. Dosimetric planning was based on HyperArc (Varian Medical System) which is a relatively new isocentric VMAT technique developed specifically for non-coplanar, multileaf collimator (MLC)-based stereotactic radiotherapy with automated treatment optimization and dose delivery; the clinical and dosimetric planning can be found in Figures -. Dosage and organ constraints, evaluation of the iso-dosage curve goals as well as the evaluation of the Paddick index were performed in accordance with published guidelines [,]. Before treatment, we administer a 16mg intramuscular deposit dexamethasone injection in order to reduce the risk of cerebellar tonsil herniation due to the important edema from the cerebellar metastasis. Tomographic images obtained with the Cone Beam CT system, integrated into the LINAC, showed a complete (100%) correlation of the images obtained during simulation and planning. Finally, the effective time of treatment was of four minutes.\nTreatment was delayed as per the patient’s request for more time to consider and on April 5, 2021, the procedure was finally performed without complications and in an outpatient setting. A follow-up was programmed 15 days after treatment at which the patient presented significant clinical improvement (absence of headaches, nausea, dizziness, photophobia, and normal balance and gait). There was no evidence of radiation toxicity, and the cognitive function was normal. A control MRI on July 17, 2021, showed a clear reduction in the size of both lesions as well as complete resolution of the mass effect produced by the cerebellar mass; a comparison of the pre- and post-treatment scans can be found in Figures -.\nAt the moment, the patient remains in continuous follow-up, with the last reported telephonic follow-up, on September 2, 2021, in which the patient reported being asymptomatic and carrying out all of his regular day-to-day activities without any limitations.
[[68.0, 'year']]
M
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{'6649918-1': 1}
44
8693539-1
34,956,805
comm/PMC008xxxxxx/PMC8693539.xml
Anti-NMDA Receptor Encephalitis Misdiagnosed As Generalized Anxiety Disorder: A Case Report
A 68-year-old female patient was admitted to the hospital on December 2, 2020, due to being “anxious and easily frightened for 3 months, psychomotor retardation, and affected by urinary incontinence for half a month.” The patient had no mental illness before and developed symptoms 3 months before admission. These included waking up early, being nervous and afraid for no apparent reason, and being fearful of leaving the house. The patient was upset, sensitive, and cried occasionally. In addition, the patient needed walking support (e.g., hands on the wall) at home to prevent falling. The patient had been hospitalized at a local mental health center 2 months prior to the present admission, where she was diagnosed with “GAD.” She received paroxetine (20 mg/d), tandospirone (30 mg/d), and oxazepam (15 mg/d). Her symptoms improved, and so she was discharged. She reported that she took the medications regularly according to the instructions. However, half a month prior to admission at our hospital, the patient experienced a relapse characterized by anxiety, fear, small steps while walking, reluctance to come out of her home, speaking less, and being slow to respond, as well as urinary incontinence. In addition, her social skills declined significantly, and the patient could not take care of herself independently. The patient had been diagnosed with type-II diabetes 4 years previously. No other comorbidities were reported. The patient had no abnormalities in her personal history, menstrual history, marriage and childbirth history, or family history.\nPhysical examination after admission revealed she had normal limb muscle strength and tone. The finger-to-nose, rapid alternating movement, heel-to-shin tests, and Romberg’s sign were normal. However, her gait was not stable and she took small steps. She was negative for pathological signs and meningeal irritation. In a psychological assessment, the patient exhibited clear consciousness, disorientation to place and time, passivity during interactions with few answers to questions, no hallucinations or delusions, a decline in memory and cognition; and a reduction in daily physical activities and energy levels. She felt distraught with a slight tremor in her hands.\nHer level of thyroid-stimulating hormone (TSH) was 6.280 µIU/mL (0.270-4.200); and she was normal for total T3, total T4, free T3, and free T4. Her level of anti-thyroglobulin antibody (anti-Tg) was 235.60 IU/mL (<115.00), and that of anti-thyroid peroxidase antibody (anti-TPO) was 238.70 IU/mL (<34.00). A color Doppler ultrasound showed diffused thyroid lesions with nodular changes (nodules in the right lobe of the thyroid). Both a CT examination (Figure ) and an MRI (Figure ) of the head showed brain atrophy and leukoaraiosis. A chest CT and pelvic ultrasonography were normal. EEG recordings revealed diffuse slow waves. No epileptic activity or extreme delta brush was observed. The patient’s Hamilton Anxiety Scale (HAMA) score was 22, indicating moderate anxiety. Her Hamilton Depression Scale (HAMD) score was 13, indicating a likelihood of depression. Her Mini-Mental State Examination (MMSE) score was 14, indicating dementia.\nThe differential diagnosis was as follows: 1) rapidly progressive dementia, 2) type-II diabetes, and 3) subclinical hypothyroidism. After admission, the patient was treated with venlafaxine (75 mg/d) and oxazepam (15 mg/d). She showed a rapidly progressive decline in cognitive function, emotional dysregulation, paroxysmal body shaking, slow performance, abnormal gait, constipation, and urinary incontinence. However, the reason for the rapidly progressive dementia was unknown. Thus, lumbar puncture and cerebrospinal fluid examination were performed with the following results: cerebrospinal fluid glucose: 6.30 mmol/L (2.50-4.50); protein: 0.87 g/L (0.15-0.45); and anti-glutamate receptor (NMDA) ratio: 1:3.2 (IgG).\nBased on these results, the diagnosis was changed to AE. Accordingly, the patient was transferred to the neurology department and treated with immunoglobulin (IVIG, 20 g/d via intravenous infusion for 5 days) and methylprednisolone (1000 mg/d via intravenous infusion for 3 days). The dosage of methylprednisolone was dropped by half every 3 days (till 48 mg/d) and was given orally. After treatment, the patient showed a gradual recovery in cognitive and emotional function, her body shaking disappeared, and her gait was stable. Her EEG was normal. Both medications were stopped gradually. The patient was discharged 24 days after administration and had resumed a normal life without relapse at a 6-month follow-up.
[[68.0, 'year']]
F
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{}
45
8693546-1
34,956,779
comm/PMC008xxxxxx/PMC8693546.xml
A Hematologic Disease Disguised as Cutaneous Candidiasis
A 44-year-old female with a history of asthma, essential hypertension, class 3 obesity, depression, and poor social and economic background was intermittently followed during the previous four years for persistent cutaneous candidiasis with intertrigo in the inframammary, inguinal, and lower abdominal regions (Figure ).\nShe had been treated with topical antifungal, oral fluconazole and oral itraconazole with no improvement, which was believed to be because of poor hygiene and questionable therapeutic compliance. A worsening in the skin rash with exudate, pruritus, and a change to a violaceous colour, with scaly papules and vesicles (Figures , ) led to the performance of a skin biopsy which revealed (Figure ) orthokeratotic hyperkeratosis in the epidermis with areas of parakeratosis and, in the papillary dermis, there was an infiltrate of cells with eosinophilic cytoplasm and reniform nuclei that showed positive CD1a and S100 proteins on the immunohistochemistry and negative CD163 (Figure ).\nThe patient denied constitutional, musculoskeletal, neurological, or urinary complaints. She underwent a complete blood count, complete metabolic panel, brain magnetic resonance imaging (MRI), thoracic-abdominal-pelvic computed tomography (CT), and bone scintigraphy. Brain MRI depicted mild chronic microvascular changes in the white matter, unchanged from a prior study. CT demonstrated a thickening of the renal pelvis (4 mm) in the right kidney with a slight urothelial dilation (Figure ). The rest of the exams did not reveal further organ involvement.\nAfter considering the skin histology, the extensive cutaneous involvement, and the infiltrative urothelial involvement, it was evident this was a multi-system process. A consultation with Hematology/Oncology, led to induction treatment with prednisolone and vinblastine-based chemotherapy. At six weeks of chemotherapy, there was a partial regression of the skin lesions (Figure ) and a resolution of the urothelium lesion in imaging exam (CT).\nThe disease was in continuous regression and considering the extension of affected skin tissue a second round of chemotherapy with prednisolone and vinblastine was administered for six weeks. There was a resolution of all the lesions following this second round, and the patient underwent maintenance therapy consisting of administrating mercaptopurine daily and prednisolone/vinblastine every three weeks during 12 months, staying in remission (Figure ).\nSix months after the end of maintenance therapy the patient had a recurrence of the disease and started second-line chemotherapy with clofarabine and cytosine arabinoside (ARA-C). The patient did not comply with the treatment and the disease progressed. As a result of skin ulceration, she developed skin and soft tissue infection that evolved into septic shock and did not survive despite intensive care support.
[[44.0, 'year']]
F
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{'7500710-1': 1}
46
8693547-1
34,956,782
comm/PMC008xxxxxx/PMC8693547.xml
Response to Immunotherapy in Adenocarcinoma Lung With Gastric Metastasis: A Rare Case Report and Review of Literature
A 72-year-old male, known hypertensive on medication, non-smoker, no family history of cancer presented with complaints of pain in the right hip with difficulty in walking in January 2019. On evaluation, a pathological fracture was found at the neck of the right femur. Magnetic resonance imaging of the spine was done, which revealed osteophyte complexes at C3-C4, C4-C5, C5-C6 vertebrae causing narrowing of neural foramina. Multiple T2-hyperintense lesions in lung parenchyma were an incidental finding. Upon further evaluation with positron emission tomography-computed tomography (PET-CT) scan of the whole body, mass in the apex of the right lung, right hilum, mediastinal lymph node, soft tissue wall thickening in the proximal stomach along with multiple liver and bone metastases were found. Upper gastrointestinal (GI) endoscopy revealed a proximal gastric growth from which a biopsy was taken. Histopathology showed poorly differentiated adenocarcinoma. A provisional diagnosis of carcinoma stomach with distant metastasis was reached. But immunohistochemistry came out to be positive for thyroid transcription factor-1 (TTF-1) and cytokeratin-7 (CK-7), while negative for cytokeratin 20 (CK-20) (Figures -).\nSo, a possibility of metastasis from a lung primary was considered. It was confirmed by a biopsy from the lung mass that revealed adenocarcinoma as the histopathology. On immunohistochemistry, it was positive for TTF-1 and CK-7 while negative for CK-20 and synaptophysin. Analysis for anaplastic lymphoma kinase, epidermal growth factor receptor, and receptor tyrosine kinase 1 were all negative but programmed death ligand 1 (PD-L1) tumor proportion score (TPS) was 90%. So, the final diagnosis was adenocarcinoma lung with multiple lung, liver, femur, as well as gastric metastases.\nFor the pathological fracture, he underwent fixation by intramedullary nailing followed by palliative external beam radiotherapy 8 Gy in a single fraction. He received 10 three-weekly cycles each of Inj. pembrolizumab 200 mg as intravenous infusion and Inj. denosumab 120 mg subcutaneously from March 2019 to September 2019. An interim PET-CT scan done after four cycles of immunotherapy in June 2019 showed a near-complete metabolic response (Figures -).\nAfter 10 cycles, Inj. pembrolizumab was discontinued as the patient was unwilling to continue due to personal reasons. He was then started with chemotherapy, Inj. pemetrexed 500 mg/m2 and Inj. bevacizumab 15 mg/kg in October 2019. Following this, the patient developed grade 1 maculopapular rash, pedal edema, and grade 2 diarrhea, which were managed conservatively. After that the patient did not opt for the continuation of chemotherapy. The next visit of the patient was in February 2021 with complaints of cough and breathlessness. On re-evaluation with PET-CT scan, progressive disease was found in the primary site (Figures , ).\nPalliative radiotherapy of 30 Gy in 10 fractions to the primary lesion was delivered through anteroposterior and posteroanterior portals of 10 megavolt energy each in April 2021 via linear accelerator (Elekta-Versa HD) which was tolerated well (Figure ).\nIn June, the patient developed an altered sensorium and contrast-enhanced magnetic resonance imaging of brain revealed multiple brain metastases for which the patient received palliative whole-brain radiotherapy of 30 Gy in 10 fractions over two weeks from the same linear accelerator. His condition further deteriorated, and in July, the patient succumbed to disease progression.
[[72.0, 'year']]
M
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47
8693548-1
34,956,778
comm/PMC008xxxxxx/PMC8693548.xml
Bilateral Thalamic Stroke Arising From an Occlusion of the Artery of Percheron: Barriers to Diagnosis, Management, and Recovery
A 90-year-old male was found in his home slumped to his right side and unable to be awakened. Paramedics calculated an 8/15 Glasgow Coma Scale (GCS) score, which remained the same on admission. On presentation to the hospital, the patient had left facial droop, bilateral pinpoint pupils, and right-sided weakness. The National Institutes of Health Stroke Scale (NIHSS) score on admission was 26, suggesting a severe stroke. All other observations on admission were non-revealing, including vital signs, biochemical tests, and systems review.\nThe patient’s neurological medical history included two previous transient ischemic attacks and suspected dementia. Other past medical history included chronic obstructive pulmonary disease, hypertension, abdominal aortic aneurysm repair, stage 3 chronic kidney disease, adult polycystic kidney disease, hypercholesterolemia, and aortic valve sclerosis. He was an ex-smoker of unknown pack-years and prior to admission was living independently.\nInitial head CT performed only showed chronic small vessel disease with periventricular leukoaraiosis, consistent with his age. Thrombolysis was initiated with an intravenous tissue-plasminogen activator, however, the patient’s GCS declined to 6/15 approximately 40 minutes after the start of thrombolysis. A repeat head CT was performed, again showing no acute findings. To prevent further deterioration, a decision to monitor the patient’s condition conservatively was made.\nOver the next few days, the patient remained very somnolent. When the patient was able to awaken, he was only capable of responding to simple commands. Speech and language therapists noted that fatigue was limiting conversations, with the patient speaking with imprecise articulation and at a low volume. Occupational therapists concurred that the patient was poorly engaged during sessions, while physiotherapists classified this patient as having limited rehabilitation potential.\nStroke was finally confirmed upon a third head CT several days after admission, which showed bilateral thalamic infarcts. Other findings included hyperdensity at the basilar tip and left posterior cerebral artery, likely due to wall calcification of vessels. An MRI revealed bilateral hyperintensities in the thalami, consistent with acute bilateral thalamic stroke, with small left parietal cortical infarction (Figure ).\nImaging also confirmed the arterial location of the infarction, a single branch of the pre-communicating (P1) segment of the left posterior cerebral artery known as the artery of Percheron (AOP). Over the next month, the patient participated in multidisciplinary rehabilitation sessions. He had a gradual return of physical function and with it, his sense of humor returned, much to the delight of his family and the attending staff. He was unable to care for himself independently and was eventually discharged to a care home. Six months later, he was mobile with a walking stick and had a reasonable quality of life. One year after the initial presentation to the hospital, he passed away from an intercurrent chest infection.
[[90.0, 'year']]
M
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48
8693695-1
34,956,793
comm/PMC008xxxxxx/PMC8693695.xml
COVID-19-Induced Guillain-Barré Syndrome
A 47-year-old male with a past medical history notable for hypertension on metoprolol succinate, morbid obesity, and pre-diabetes presented to the emergency department (ED) with a chief complaint of generalized weakness. The patient tested positive for COVID-19 and exhibited mild unspecified respiratory symptoms. He was subsequently discharged home to recover in isolation per the CDCs COVID-19 response protocols. One week later, the patient returned to the ED for ongoing symptoms and was admitted requiring supplemental oxygen for hypoxia. Upon admission to the hospital, the patient was noted to have difficulty standing and ambulating. Two days into his inpatient stay, the patient developed urinary retention issues requiring intermittent catheterization. Three days later, he developed facial weakness and numbness. The clinical diagnosis of GBS was suspected and subsequent EDX studies reported AIDP. The patient was treated with a five-day course of intravenous immune globulin (IVIG). Three days after the completion of his IVIG treatment, the patient noted improvement with right upper extremity anti-gravity strength.\nThe patient was transferred to inpatient rehabilitation with significant proximal lower extremity weakness. The bilateral upper extremities demonstrated slight weakness. The bilateral lower extremities demonstrated a significant loss of strength, 1/5 dorsiflexion, and 3/5 plantar flexion bilaterally. The patient also reported diminished sensation to light touch in bilateral upper extremities in all dermatomes. His blood pressure upon rehabilitation admission was 110/73 mmHg.\nPrior to hospitalization, the patient was independent with mobility and all activities of daily living. Upon evaluation in the inpatient rehabilitation, the patient was at a significant functional decline from baseline, requiring dependent assistance with toileting hygiene, showering, upper body dressing, lower body dressing, footwear management, rolling left and right, and all transfers. The patient was unable to ambulate due to his level of impairment. In inpatient rehabilitation, the patient completed three hours total of physical, occupational, and speech therapy per day five days a week with exercises aimed to improve balance, mobility, activities of daily living, fine motor skills, cognition, and breath support.\nAfter completing four weeks of inpatient therapy, the patient was independent with supine to sit, upper and lower body dressings, and rolling right and left in bed. He required minimal assistance to lift the left lower extremity into the bed and moderate assistance with wheelchair-to-bed transfers and bed mobility. He was able to stand with the assistance of his spouse and by using significant reliance on bilateral upper extremity support on a walker for stability and offloading lower extremities. He required a power wheelchair for mobility and was unable to transfer in and out of the car thereby requiring a wheelchair van for transportation. Final muscle strength grading was not documented. His blood pressure remained stable throughout his stay on metoprolol succinate and was 121/65 mmHg on discharge.
[[47.0, 'year']]
M
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{}
49
8693699-1
34,956,792
comm/PMC008xxxxxx/PMC8693699.xml
Typhoid Fever and Helminth Coinfection: A Pediatric Case Report
This is a case of a 4-year-old male who was brought to our clinic with complaints of four-day history of constipation, dry cough, vomiting, high fever (104 °F), abdominal pain with bloating, headache, and rash. The patient’s symptoms started gradually with fatigue, loss of appetite, muscle aches, cough, bloated abdomen, and poor oral intake, prior to presenting to the hospital. The parents assumed it was stomach flu, and so managed their child’s symptoms with Tylenol and soups. However, the patient continued to have constipation, abdominal discomfort, and eventually maculo-papular rashes on the head, face, and extremities erupted (Figure ).\nOn day 1, upon admission to the hospital, IV fluid with 0.9% normal saline solution was started, due to signs of dehydration, bradycardia, and hypotension. Norepinephrine was also administered. Lab samples (stool, urine, and blood) were collected for analysis, and abdominal ultrasound was ordered which showed clumps of worms in the jejunum which explained the constipation our patient had (Figure ).\nStool test for helminth (stained with bile) showed rounded 45-78 micrometer long thick-shelled eggs indicative of roundworm infestation (Ascaris lumbricoides). Blood test came back positive for typhoid DNA and increased level of eosinophils with relatively high leukocytes. The rest of the complete blood count (CBC) was normal including a chest X-ray.\nFollowing day 2 of in-hospital admission, the patient’s condition remained unstable due to high fever (102 °F), vomiting, and fatigue. Antibiotics were initiated with ceftriaxone, antipyretics, albendazole, and more IV fluids.\nFinally on day 3, the patient’s symptoms improved clinically, although body rashes persisted. CBC had normalized, and he was later discharged home with one week prescription of azithromycin and albendazole. The patient was also prescribed antihistamine cream to help stop the itching from the rash.
[[4.0, 'year']]
M
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{}
50
8694018-1
34,956,799
comm/PMC008xxxxxx/PMC8694018.xml
A Stiff Finger: A “Concrete” Diagnosis
The patient was a 31-year-old male, a right-hand-dominant construction worker who was referred to our plastic surgery unit from a local minor injuries unit. He complained of pain in his left ring finger, following an inadvertent injury with a spray gun containing Newton 103-S (a type of liquid cement). The patient had been wearing protective gloves at the time of injury. He had no past medical history, took no regular medications, and had no allergies.\nThe patient had been given tetanus immunisation by the referring hospital. He had a plastic surgery review approximately three hours post-injury. On examination, his left ring finger was swollen, erythematous with necrotic skin on the volar aspect of the finger (Figure ). There was no evidence of distal vascular compromise and the dorsal skin was well-perfused. He had a complete loss of sensation in the distribution of the ulnar digital nerve; however, the radial digital nerve was clinically intact. There was decreased range of movement at both the proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ). The palmar skin was not involved.\nBlood results and observations were within normal ranges. No X-rays were taken at the time of presentation. Broad-spectrum IV antibiotics were commenced, and the patient was taken to theatre for urgent debridement and washout under general anaesthetic.\nThe initial surgical approach consisted of Bruner incisions. Significantly hardened concrete was identified in the subcutaneous tissues (Figure ). It was evident that skin and subcutaneous tissues were non-viable and were debrided, improving access. The pH of the wound was 8.5, in keeping with the alkaline substance injected; irrigation continued until pH returned to 7. The ulnar digital artery was thrombosed, but the radial digital artery was patent. The concrete had penetrated the flexor sheath, surrounding both flexor tendons. Subsequent flexor sheath washout from A1 to A5 confirmed that both tendons were in continuity but had undergone surface changes secondary to contact with the concrete.\nA second look was performed at 48 hours; the distal digit remained viable with the flexor tendons appearing healthy. Tendon glide was impeded by friction within the flexor sheath. Access incision was made into the palm, which revealed further cement material. The passive range of movement was reassessed, which confirmed PIPJ and DIPJ to be in good condition. Further debridement of devitalised soft tissue resulted in a large defect of almost the full length of the volar aspect of the ring finger exposing the intact flexor apparatus pulleys and tendons (Figure ).\nThe patient was counselled extensively regarding ongoing management, which principally consisted of either reconstruction of the volar soft tissue defect or potential amputation through the middle phalanx. He was counselled that the reconstructive option would result in a stiff and potentially insensate finger but could preserve length, while amputation might provide a faster recovery and better overall functional outcome. The patient opted for reconstruction and preservation of as much length of the digit as possible.\nAt one week from the initial injury, a cross-finger flap from the ipsilateral middle finger was performed, reconstructing the volar soft tissue defect (Figure ). The patient was discharged with oral antibiotics.\nAfter three weeks, the flap was divided and inset. However, the patient developed a wound infection five weeks after reconstruction, necessitating further washout and IV antibiotics.\nAt four months post-injury, the digit had an active range of movement of 20-84 degrees at the metacarpophalangeal joint (MCPJ); both PIPJ and DIPJ were in fixed 30 degrees of flexion. The protective sensation was maintained in the radial aspect of the digit, and the patient did not develop issues with pain subsequently. He was followed up via telephone consultation at 18 months postoperatively, and he reported that he had no functional limitations on daily activities, and was back to work. The skin overlying the volar defect of the ring finger and grafted area on the dorsum of the middle finger has healed well (Figures , ).
[[31.0, 'year']]
M
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{}
51
8695605-1
34,957,243
comm/PMC008xxxxxx/PMC8695605.xml
Case Report: A Giant Left-Ventricular Intramural Pseudoaneurysm Arise From Ruptured Left Sinus of Valsalva Aneurysm
A 46-year-old male patient was admitted to the hospital with intermittent back pain and chest tightness for 2 weeks. The patient works in ozone disinfection. Prior to symptom onset, he had a history of acute ozone inhalation. He recalled smelling something more pungent than usual for several days. Before coming to our hospital, he had not undergone any treatment. In addition, he denied any history of chest trauma. He had suffered from hypertension for over a decade and was treated with oral nifedipine and metoprolol. However, medication poorly controlled his blood pressure. The highest recorded systolic blood pressure with treatment was 180 mmHg. His blood pressure upon admission was 148/91 mmHg.\nAn echocardiogram revealed a left SVA that ruptured into the left-ventricular myocardium, forming an echo-lucent cavity (). The left-ventricular wall had thickened resulting in uncoordinated motion and reduced systolic function. Moreover, moderate eccentric aortic regurgitation was also noted. Furthermore, CT angiograms better captured a large, left-ventricular, IPA arising from a small perforation in the left SVA (). The adjacent left ventricle and interventricular septum were compressed. With CMR examination, late gadolinium enhancement (LGE) clearly demonstrated the left-ventricular IPA with distal thrombus and a linear enhancement of the IPA wall, compatible with myocardial fibrosis ().\nSubsequently, the patient underwent surgery where the perforation was sutured and repaired, and the left aortic valve was lengthened with pericardial patches. Three weeks after surgery, a follow-up echocardiogram demonstrated the cessation of the abnormal blood flow in the left sinus of Valsalva ().
[[46.0, 'year']]
M
{'19552797': 1, '1595558': 1, '10585023': 1, '31629750': 1, '20083588': 1, '20980218': 1, '33162165': 1, '28715576': 1, '9201120': 1, '5773118': 1, '28272209': 1, '34957243': 2}
{}
52
8695686-1
34,957,196
comm/PMC008xxxxxx/PMC8695686.xml
Optic Foraminotomy for Clipping of Superior Carotid-Ophthalmic Aneurysms
Patient 1: A 64-year-old man with a left inferior visual field deficit and headache. The CT angiography showed a left superior carotid-ophthalmic aneurysm (4 × 5 mm) ().
[[64.0, 'year']]
M
{'897986': 1, '3989589': 1, '21691999': 1, '5457192': 1, '27097005': 1, '8837792': 1, '30171310': 1, '28922882': 1, '1123662': 1, '17512328': 1, '7777297': 1, '32949801': 1, '12984895': 1, '9322855': 1, '27561016': 1, '5674088': 1, '3760967': 1, '707174': 1, '31108071': 1, '26438000': 1, '5554360': 1, '7277004': 1, '10794306': 1, '12500708': 1, '33197635': 1, '993805': 1, '28422878': 2, '34357012': 2, '33973028': 1, '34957196': 2}
{'8695686-2': 2, '5406094-1': 1, '8305784-1': 1}
53
8695686-2
34,957,196
comm/PMC008xxxxxx/PMC8695686.xml
Optic Foraminotomy for Clipping of Superior Carotid-Ophthalmic Aneurysms
Patient 2: A 43-year-old woman with subarachnoid hemorrhage, classified as Fisher I, Hunt, and Hess II. In the digital 3D angiographic reconstruction multiple aneurysms are observed: a right M1 aneurysm and a right superior carotid-ophthalmic aneurysm ().
[[43.0, 'year']]
F
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{'8695686-1': 2, '5406094-1': 1, '8305784-1': 1}
54
8695756-1
34,956,855
comm/PMC008xxxxxx/PMC8695756.xml
Imaging Manifestations of Intrahepatic Reactive Lymphoid Hyperplasia: A Case Report and Literature Review
A 77-year-old woman was hospitalized in the cardiology department due to atrial fibrillation. Contraindications were excluded, and atrial fibrillation (AF) ablation was performed on an optional schedule. However, abdominal contrast-enhanced computed tomography (CT) scan found a circular and low-density lesion in the Segment 4 of the liver with unclear border, approximately 15 mm× 12 mm in size, which was mild progressive enhanced in the arterial phase and portal phase. HCC was suspected, but no hepatic cirrhosis and history of hepatitis (). Tumor markers, including CEA, CA199, CA125, AFP, were within normal range, hepatitis panel was negative, and hepatic function was normal.\nTo confirm the diagnosis, the patient underwent further examinations. Abdominal magnetic resonance imaging (MRI) disclosed one nodule in the segment 7, one nodule in the segment 5, and two nodules in the segment 4 of the liver (4, 6, 17, and 6 mm in diameter), respectively. The larger one was located in the segment 4 of liver, with hypointense on T1-weighted images (T1WI) and hyperintense on T2-weighted images (T2WI), which showed significant enhancement on the arterial phase and slight washout on the portal phase. In the delayed phase, the edge of the tumor was underscored as a circular enhancement which is unsimilar to the enhancement method of dynamic CT. It showed a significant restriction of diffusion on diffusion weighted images (DWI) and apparent diffusion coefficient (ADC). Other lesions in segments 7 and 5 showed the same hemodynamic characteristics as the tumor in segment 4 (). Based on MRI findings, it is considered as tumorous lesions of the liver.\nFor further differential diagnosis, the patient underwent positron emission tomography-computer tomography (PET-CT) examination, founding that the segment 4 of liver had a slightly low-density lesion with increased uptake of 18F-fluoro-deoxy-glucose (FDG), and SUVmax of early and delayed enhancement imaging was 4.81 and 5.24, respectively. The detention index was 8.9%. However, the lesions in segments 7 and 5 of the liver showed no significant increase in FDG uptake (). As all images suggested HCC, the medial segment of the liver was finally surgically removed.\nSurgical removal of a piece of left medial lobe of liver tissue, about 6 cm × 4 cm × 2.5 cm in size, the cut surface shows an expanded lumen structure, and a gray-white mass in the liver parenchyma. The size is about 2.5 × 2cm, part of the boundary is unclear, and the texture is soft. The HE-stained sections under low-power microscope showed that massive lymphoid tissues proliferated in the lesion and formed massive lymphoid follicles, and the peripheral lymphoid tissues of the lesion grew around the small bile ducts, but no clear lymphoepithelial lesions were seen. The interfollicular area is dominated by small lymphocytes, and many plasma cells can be seen. In the lymphatic tissue, there were homogeneous red-stained collagen-like deposits around some small blood vessels. Immunohistochemical results were as follows: Bcl-2(−), Bcl-6(germinal center +), CD10(germinal center +), CD20(+), CD23(+), CD3(+), Ki-67(germinal center +), CD5(+), CyclinD1(−), TDT(−), kappa/lambda ratio about 2:1. EBV negative by qRT-PCR method (). A genetic study of the immunoglobulin heavy chain (IgH) clonality on the DNA of tumor tissues was performed using capillary electrophoresis method, which was reported previously (). The results showed that no clonal IgH gene rearrangement was detected: IGH (−), IGK (−), IGL (−). Therefore, the possibility of extranodal marginal-zone lymphoma (MALT) was ruled out, and the final diagnosis was RLH. Combined with imaging, pathology, and clinical manifestations, the clinical diagnosis was multifocal RLH in the liver. Three months after the operation, a re-examination of the abdominal ultrasound showed no signs of recurrence.
[[77.0, 'year']]
F
{'16965640': 2, '7514058': 1, '33179624': 1, '15681487': 1, '29517697': 1, '30720334': 1, '15948117': 1, '17879417': 1, '6893912': 1, '10364042': 1, '21937394': 1, '16935975': 1, '31528094': 1, '78921': 1, '26191310': 1, '33949938': 1, '32417128': 1, '29485448': 1, '29517544': 1, '22899877': 1, '34956855': 2}
{'1579220-1': 1, '1579220-2': 1}
55
8695790-1
34,955,908
comm/PMC008xxxxxx/PMC8695790.xml
Case Report: Repeated Transcranial Magnetic Stimulation Improves Comorbid Binge Eating Disorder in Two Female Patients With Treatment-Resistant Bipolar Depression
Patient 1 was a 45-year-old right-handed woman, who sought treatment for a depressive episode. The current episode onset was placed after a switch from sertraline to vortioxetine due to unbearable side effects (nausea and headache). She suffered from her first depressive episode at the age of 25, then alternating depressive and hypomanic episodes, which led clinicians to a diagnosis of BD-II.\nThe patient has also been suffering from EDs since her adolescence: she was diagnosed with anorexia nervosa at the age of 13; she then shifted to a bulimic eating pattern, with binge episodes followed by purging behaviors. This phase lasted for 10 years, followed by a complete remission until the age of 38. At this age she developed BED. Once a week or more she used to wake up at night and eat everything she could find in the fridge, including raw food. After these episodes she used to feel guilty and nauseated, but she did not show purging behavior anymore. She felt very uncomfortable due to either the loss of control or her weight gain. Her private psychiatrist then diagnosed her with BED, but apparently, she did not receive any psychological or pharmacological specific support. In the following years she had alternating periods of remission with periods of active disease. She denied alcohol or other psychoactive substances consumption. In the 2 months previous to our study, she had gained 12 kg, with 3–4 binge episodes per week on average. She denied medical comorbidities. When she first came to our attention, her therapy was the following: lamotrigine (150 mg daily), vortioxetine (20 mg daily). She was suffering from a depressive episode defined as mild according to the Hamilton Rating Scale for Depression (HAMD) and moderate according to the Montgomery-Åsberg Depression Rating Scale (MADRS) ().
[[45.0, 'year']]
F
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{'8695790-2': 2}
56
8695790-2
34,955,908
comm/PMC008xxxxxx/PMC8695790.xml
Case Report: Repeated Transcranial Magnetic Stimulation Improves Comorbid Binge Eating Disorder in Two Female Patients With Treatment-Resistant Bipolar Depression
The second patient we are reporting is a 28-year-old right-handed woman, who came to our attention for a severe depressive episode. Her psychopathological onset is placed 10 years ago; she developed her first depressive episode with comorbid panic attacks. From that moment the patient has alternated phases of depression with sporadic episodes of elation, thus a sign of hypomanic episodes, which led clinicians to a diagnosis of BD-II. Her depressive phases used to have a seasonal pattern, with autumn or winter worsening. When she came to our attention (November 2020), the current episode had been lasting for 3 months, according to her seasonal pattern. She reported low consumption of alcohol in social circumstances and sporadic use of cannabis in her adolescence.\nRegarding her ED, binging behaviors were reported to happen from the first diagnosis of depression, with various degrees of intensity and severity, and appeared to be more intense in depressive phases. Binge eating episodes during depressive phases used to be daily. No compensatory behaviors were ever observed. Notably, her first BED diagnosis was given in our center during her last depressive episode, as she had always been trying to hide her eating behaviors, even with physicians. Along with the current depression, she referred almost daily binge eating: after her dinner she used to go out and then buy and rapidly eat large amounts of high-fat food. This used to cause both physical and psychological distress.\nIn her past pharmacological history, many pharmacological therapies had been prescribed (i.e., valproate, fluoxetine, citalopram, venlafaxine, and bupropione) and when she came to our attention her therapy was clomipramine (150 mg daily) and pregabalin (225 mg daily). Her depressive symptoms at baseline were severe according to both MADRS and HAMD ().
[[28.0, 'year']]
F
{'19833552': 1, '23290497': 1, '24606720': 1, '29467437': 1, '29308739': 1, '3697730': 1, '29726344': 1, '30464467': 1, '16084855': 1, '30793079': 1, '32171414': 1, '27367316': 1, '31824745': 1, '33282175': 1, '29742385': 1, '20060105': 1, '24512735': 1, '25215552': 1, '18087209': 1, '24206365': 1, '30520709': 1, '32860557': 1, '30149272': 1, '7080884': 1, '23658085': 1, '27729854': 1, '31443880': 1, '22271579': 1, '29077650': 1, '34955908': 2}
{'8695790-1': 2}
57
8695792-1
34,956,909
comm/PMC008xxxxxx/PMC8695792.xml
A Combined Histone Deacetylases Targeting Strategy to Overcome Venetoclax Plus Azacitidine Regimen Resistance in Acute Myeloid Leukaemia: Three Case Reports
Patient 1: A 65-year-old male was diagnosed with AML in January 2020 with the manifestation of leukocytosis, thrombocytopenia and anaemia. BM aspiration revealed a hypercellular BM with 50% blasts. Flow cytometry showed the immunophenotype of myeloid blasts. Cytogenetics revealed a complex karyotype, and a molecular panel identified aberrations in ASXL1, CEBPA, JAK2, and RUNX1. None of the 41 gene fusions were detected by using multiple RT–PCR assay (). Therefore, AML with adverse risk was diagnosed according to genetic risk stratification (). After one course of induction treatment with the IA regimen [idarubicin 12 mg/m2 day1-3, cytarabine 100 mg/m2 continuous infusion day1-7.], the patient achieved complete remission with minimal residual disease as low as 5.8x10-4 by flow cytometry analysis. Genetic analyses showed that all gene mutations were negative. Subsequently, the patient refused bone marrow transplant for financial reasons. He received one course of the IA regimen and 3 courses of the high-dose Ara-c (HiDAC) regimen [cytarabine 2 g/m2 over 3 h every 12 h on day1–3.] as consolidation therapies. However, the remission duration only lasted for 11 months. In November 2020, relapsed BM morphology was detected, with 17.5% blasts concurrent with molecular aberration recurrence. Therefore, relapsed AML was diagnosed. Initially, venetoclax combined with azacitidine [VA, venetoclax once daily (100 mg day1, 200 mg day2, 400 mg day3-28) and azacitidine 75 mg/m2 day1-7.] was administered as a salvage therapy, an effective regimen recommended for the treatment of R/R AML patients who are ineligible for intensive salvage chemotherapy, but progressive disease was observed. Then, his treatment plan switched to a chidamide combined with venetoclax plus azacitidine regimen [chidamide 5 mg daily day1-7, venetoclax 100 mg day1, 200 mg day2, 400 mg day3-21; azacitidine 75 mg/m2 daily day1-7.], and CR was achieved after one course of therapy. The patient treatment process is shown in . After 3 months of follow-up, unfortunately, the patient gave up further treatment and passed away due to disease progression. The overall survival time was 1.5 years from first diagnosis.
[[65.0, 'year']]
M
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{'8695792-2': 2, '8695792-3': 2}
58
8695792-2
34,956,909
comm/PMC008xxxxxx/PMC8695792.xml
A Combined Histone Deacetylases Targeting Strategy to Overcome Venetoclax Plus Azacitidine Regimen Resistance in Acute Myeloid Leukaemia: Three Case Reports
Patient 2: A 57-year-old male was diagnosed with AML in July 2016. Investigation revealed a pancytopenia. BM examination showed a hypercellular marrow with 65% myeloid blasts. Flow cytometry analysis showed the immunophenotype of myeloid blasts. Cytogenetics revealed del () (q22q36), and a molecular panel identified aberrations in DNMT3A and IDH2. The patient achieved CR after 1 cycle of the IA regimen [idarubicin 12 mg/m2 day1-3, cytarabine 100 mg/m2 continuous infusion day1-7.] and received 6 courses of the HiDAC regimen [cytarabine 2 g/m2 over 3 h every 12 h on day1–3.] as consolidation therapies while not adopting allogeneic haematopoietic stem cell transplantation. The patient experienced his first relapse 2 years after first remission with a 9% immature cell level in the BM and was treated with the CAG [cytarabine 10 mg/m2 every 12 h, day1-14; aclarubicin 5-7 mg/m2, daily on day1-8; and concurrent use of G-CSF 200 µg/m2/day.] regimen for 3 cycles, resulting in a second CR in March 2019. A second relapse occurred 20 months later. The patient began the VA regimen [venetoclax once daily (100 mg day1, 200 mg day2, 400 mg day3-28) and azacitidine 75 mg/m2 day1-7.], but no response was observed after 2 courses of therapies. Finally, the patient received a chidamide combined with venetoclax plus azacitidine regimen [chidamide 5 mg daily day1-7, venetoclax 100 mg day1, 200 mg day2, 400 mg day3-21; azacitidine 75 mg/m2 daily day1-7.] as salvage therapy as described above. The patient achieved his third CR. Treatment process is shown in . There were no infectious complications observed with the combination, and the duration of neutropenia was 10 days. After 1 month of follow-up, the patient remains in CR and is preparing for transplantation.
[[57.0, 'year']]
M
{'31974170': 1, '32476595': 1, '29545346': 1, '30361262': 1, '23291630': 1, '29912596': 1, '27895058': 1, '32948748': 1, '28814980': 1, '31160589': 1, '25040094': 1, '30185627': 1, '32786187': 1, '28140720': 1, '32294670': 1, '17097561': 1, '30892988': 1, '24413064': 1, '34956909': 2}
{'8695792-1': 2, '8695792-3': 2}
59
8695792-3
34,956,909
comm/PMC008xxxxxx/PMC8695792.xml
A Combined Histone Deacetylases Targeting Strategy to Overcome Venetoclax Plus Azacitidine Regimen Resistance in Acute Myeloid Leukaemia: Three Case Reports
Patient 3: A 60-year-old female was diagnosed with AML in December 2020. BM examination showed a hypercellular marrow with 32% myeloid blasts. A molecular panel identified aberrations in RUNX1. Karyotype was normal. All patient baseline characteristics at diagnosis and treatment characteristics are shown in . For induction therapy, the patient received the VA [venetoclax once daily (100 mg day1, 200 mg day2, 400 mg day3-28) and azacitidine 75 mg/m2 day1-7.] regimen and achieved CR after one course. Subsequently, she continued two courses of VA as consolidation therapy, but progressive disease was observed during the second course, with 67% blasts in BM. Then, a chidamide combined with venetoclax plus azacitidine regimen [chidamide 5 mg daily day1-7, venetoclax 100 mg day1, 200 mg day2, 400 mg day3-21; azacitidine 75 mg/m2 daily day1-7.] was given. After one course, the patient obtained CR. Treatment process is shown in . During the whole course, no severe adverse events occurred. After 1 month of follow-up, the patient remains in CR at the time of writing.
[[60.0, 'year']]
F
{'31974170': 1, '32476595': 1, '29545346': 1, '30361262': 1, '23291630': 1, '29912596': 1, '27895058': 1, '32948748': 1, '28814980': 1, '31160589': 1, '25040094': 1, '30185627': 1, '32786187': 1, '28140720': 1, '32294670': 1, '17097561': 1, '30892988': 1, '24413064': 1, '34956909': 2}
{'8695792-1': 2, '8695792-2': 2}
60
8695846-1
34,956,873
comm/PMC008xxxxxx/PMC8695846.xml
Case Report: Graft Versus Tumor Effect After Non-Myeloablative Allogeneic Stem-Cell Transplantation in a Patient With Brentuximab-Vedotin Refractory Sezary Syndrome
A 54-year-old Caucasian male patient was referred to our institution, initially with the diagnosis of a T-cell lymphoma, not otherwise specified, which was refractory to two courses of chemotherapy (CHOEP: cyclophosphamide, doxorubicine, vincristine, etoposide and prednisolone). At presentation an erythroderma involving >90% of the integument was predominant (). Computer tomography (CT) scans showed enlarged axillary, inguinal and cervical lymph nodes. The complete blood counts showed a leukocytosis of 24,300/µl. Flow cytometry of the pb revealed 11,664 Sézary cells/µl with CD4+CD7- phenotype and with a CD4:CD8 ratio of 85.5. Flow cytometry of the bone marrow aspirate confirmed CD30 positivity with expression of 7% in Sézary cells. Polymerase chain reaction of pb confirmed the clonality in T-cell receptor beta and gamma showing monoclonal Vβ-β2 and two clonal Vγ1-8-Jγ1.1 and 2.1 rearrangements. While conventional cytogenetics showed a normal male karyotype, fluorescent in situ hybridization (FISH) detected the deletion of chromosome 17p in 22 of 200 interphases with deletion of TP53 gene. Immunohistochemistry of both trephine biopsy () and skin histology revealed infiltrations with Sézary cells (). The skin histology also confirmed CD30 positivity with 5-10%, and the diagnosis was revised to SS.\nThe diagnosis was thus revised to Sézary Syndrome in Stage IVA (pT4 Nx M0 B2) according to the updated classification of International Society for Cutaneous Lymphomas (ISCL) and the European Organization of Research and Treatment (EORTC) ().\nSubsequently, successive therapies with 3,000,000 IU interferon alpha three times weekly for 6 months, combined with 10 mg/m2 methotrexate (MTX) and 19 courses ECP including bexarotene showed no improvement.\nSix months prior to alloHSCT an antibody-conjugate treatment with brentuximab vedotin (BV) was administered. The patient received five courses, which led to an improvement of skin lesions and their reduction to about 30% of body surface. CT scans showed no further progression of the lymph nodes, the CD4:CD8 ratio was 76.7 with 63.5% Sézary cells in the flow-cytometry, confirming stable disease according to the EORTC and ISCL classification (, ).\nDue to preexisting comorbidities, we performed an alloHSCT from an unrelated HLA identical (10/10) and cytomegaly virus matched (recipient and donor IgG positive) 30 year old male donor with non-myeloablative conditioning (fludarabine 30 mg/m² body surface area on d-4 to -2 and total body irradiation with 2 Gy on day -1) followed by infusion of pb stem cells (). Immunosuppression consisted of cyclosporine A from d-1 (blood target level 200 ng/ml) and mycophenolate mofetil (3x1000 mg per day). The patient received a total of 6.6x106 CD34+ cells/kg body weight, 1.1x108 CD3+ cells/kg body weight and 0.2x108 CD16+ cells/kg body weight. In the absence of acute graft-versus-host disease (GvHD), mycophenolate-mofetil was tapered 500 mg every 14 days from day 40 and discontinued on day 74 while cyclosporine A was tapered from day +56 and discontinued on d+196.\nThe restaging on day +30 and +90 after alloHSCT showed residual infiltration of SS cells in the FACS analysis of the bone marrow (13 and 5% of all WBC, respectively) and chimerism of 70 and 93% on sorted CD3+ cells. The CT scan on day +90 after alloHSCT confirmed the persistent lymphadenopathy. On day + 172 after alloHCT a complete hematological remission (CR) with no infiltration of SS in bone marrow trephine biopsy, 100% chimerism on sorted CD3 positive cells from bone marrow aspirate and normal pb CD4:CD 8 ratio was documented, thus confirming graft-vs-Sézary effect (). The CT scan showed no lymph node enlargements. The inspection of the skin revealed no suspect lesions.\nAfter discontinuation of immunosuppression the patient developed chronic GvHD of the ocular mucosa and the liver according to national institutes of health (NIH) criteria () on day 277 and required immunosuppressive treatment with intermediate dosage of methylprednisolone, cyclosporine A and mycophenolic acid. The immunosuppression could have been slowly tapered to 720 mg mycophenolic acid b.i.d, 5 mg prednisolone and autologous plasma eye drops as previously described (, ). Furthermore, since September 2021 ruxolitinib was added to the GvHD treatment (). Currently, 1215 days after alloHSCT the patient is in continuous complete remission of SS, having active ocular chronic GvHD.
[[54.0, 'year']]
M
{'16338616': 1, '22611160': 1, '30635287': 1, '25154828': 1, '15692063': 1, '25985053': 1, '28797780': 1, '33420392': 1, '23769990': 1, '15994282': 1, '28600132': 1, '31014144': 1, '30953028': 1, '19279331': 1, '20855822': 1, '21576639': 1, '25809616': 1, '20351328': 1, '12393457': 1, '27267447': 1, '25068422': 1, '20697072': 1, '29280595': 1, '26195720': 1, '16310068': 1, '34260836': 1, '32941647': 1, '29193659': 1, '27380960': 1, '32380458': 1, '29442161': 1, '34956873': 2}
{}
61
8695924-1
34,955,835
comm/PMC008xxxxxx/PMC8695924.xml
Case Report: Monitoring Vancomycin Concentrations and Pharmacokinetic Parameters in Continuous Veno-Venous Hemofiltration Patients to Guide Individualized Dosage Regimens: A Case Analysis
The first case was that of a 37-year-old man. At admission, the patient was diagnosed with septic shock, previous total cystectomy with ileal bladder replacement, urinary retention with pyuria, chronic renal insufficiency stage V, and neurogenic bladder. In addition, the patient’s vital signs were unstable, and noradrenaline and phenylephrine were required to maintain blood pressure after fluid resuscitation. Blood culture analyses were negative. Escherichia coli [extended spectrum beta-lactamase (ESBL) +], Enterococcus avium, and Enterococcus faecium were detected in the drainage fluid of the ileostomy. The antibiotic regimen at admission was 1000 mg meropenem q12 h ivgtt combined with vancomycin (loading dose on D1 of 1500 mg and maintenance dose of 1000 mg on D2). CVVH was also administered. From D7, the patient’s condition tended to be stable, and the CVVH frequency was reduced to every other day. On D9, puncture and catheterization of left subphrenic effusions were conducted under the guidance of B-ultrasound. Escherichia coli (ESBL+) and Enterococcus avium were identified in the drainage fluid. The intra-abdominal infection improved and the function of organs other than the kidney returned to normal. On D22, the culture of drainage fluid was negative, thus vancomycin and meropenem were stopped. On D26, the patient was transferred out of the intensive care unit and resumed routine hemodialysis.
[[37.0, 'year']]
M
{'31394493': 1, '19487930': 1, '23673472': 1, '26555059': 1, '33592353': 1, '30560582': 1, '19569969': 1, '26003633': 1, '23132513': 1, '950590': 1, '31734748': 1, '33367582': 1, '26106281': 1, '31342772': 1, '19237886': 1, '20644583': 1, '24887569': 1, '32191793': 1, '32547394': 1, '33883878': 1, '21636256': 1, '34955835': 2}
{'8695924-2': 2}

Dataset Card for PMC-Patients

Dataset Summary

PMC-Patients is a first-of-its-kind dataset consisting of 167k patient summaries extracted from case reports in PubMed Central (PMC), 3.1M patient-article relevance and 293k patient-patient similarity annotations defined by PubMed citation graph.

Supported Tasks and Leaderboards

This is purely the patient summary dataset with relational annotations. For ReCDS benchmark, refer to this dataset

Based on PMC-Patients, we define two tasks to benchmark Retrieval-based Clinical Decision Support (ReCDS) systems: Patient-to-Article Retrieval (PAR) and Patient-to-Patient Retrieval (PPR). For details, please refer to our paper and leaderboard.

Languages

English (en).

Dataset Structure

PMC-Paitents.csv

This file contains all information about patients summaries in PMC-Patients, with the following columns:

  • patient_id: string. A continuous id of patients, starting from 0.
  • patient_uid: string. Unique ID for each patient, with format PMID-x, where PMID is the PubMed Identifier of the source article of the patient and x denotes index of the patient in source article.
  • PMID: string. PMID for source article.
  • file_path: string. File path of xml file of source article.
  • title: string. Source article title.
  • patient: string. Patient summary.
  • age: list of tuples. Each entry is in format (value, unit) where value is a float number and unit is in 'year', 'month', 'week', 'day' and 'hour' indicating age unit. For example, [[1.0, 'year'], [2.0, 'month']] indicating the patient is a one-year- and two-month-old infant.
  • gender: 'M' or 'F'. Male or Female.
  • relevant_articles: dict. The key is PMID of the relevant articles and the corresponding value is its relevance score (2 or 1 as defined in the ``Methods'' section).
  • similar_patients: dict. The key is patient_uid of the similar patients and the corresponding value is its similarity score (2 or 1 as defined in the ``Methods'' section).

Dataset Creation

If you are interested in the collection of PMC-Patients and reproducing our baselines, please refer to this reporsitory.

Citation Information

If you find PMC-Patients helpful in your research, please cite our work by:

@article{zhao2023large,
  title={A large-scale dataset of patient summaries for retrieval-based clinical decision support systems},
  author={Zhao, Zhengyun and Jin, Qiao and Chen, Fangyuan and Peng, Tuorui and Yu, Sheng},
  journal={Scientific Data},
  volume={10},
  number={1},
  pages={909},
  year={2023},
  publisher={Nature Publishing Group UK London}
}
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